Orthopaedic Surgery - Bite to the Hand

Basics

Bite injuries to the hand are common and potentially serious. They may occur directly, such as from a dog, cat, or intentional human bite, or indirectly through a clenched-fist injury.

If these wounds are not recognized and treated appropriately, they can lead to significant morbidity involving the soft tissues, tendons, joints, and bones of the hand.

Clenched-Fist Injury

The classic indirect human bite injury, commonly called a “fight bite” or “clenched-fist injury,” occurs when a closed fist strikes another person’s teeth.

The injury most commonly affects the skin over a metacarpophalangeal (MCP) joint.

Although the external wound may appear small and harmless, the underlying damage may be extensive.

Deep Structural Injury

A tooth can penetrate the skin and injure the extensor tendon, joint capsule, or MCP joint itself.

Deep structural involvement has been reported in a substantial proportion of clenched-fist injuries.

Because the fist is flexed at the time of impact, the skin wound and deeper injury may not remain aligned when the fingers are subsequently extended.

Hidden Nature of Fight-Bite Wounds

When the injured finger is returned to an extended position, the skin shifts relative to the underlying tendon and joint.

As a result, the deeper injury may lie proximal to the visible skin laceration.

This can make the wound appear more superficial than it actually is and contributes to delayed diagnosis.

Synonyms

Common synonyms include clenched-fist injury and fight bite.

General Prevention

Patients should be advised to avoid unnecessary contact with unfamiliar or potentially aggressive animals and to avoid fistfighting.

The complications of clenched-fist injuries can be reduced by recognizing them early as serious wounds and initiating prompt irrigation, debridement, and appropriate antibiotic therapy.

Epidemiology

Bite injuries to the hand account for a large number of emergency department visits.

Approximately 330,000 emergency visits annually in the United States have been attributed to hand bites.

More than half of the population is estimated to experience an animal bite at some point in life, with many occurring during childhood.

Dog Bites

Approximately 4.5 million dog bites occur annually in the United States.

Dog bites may produce crushing injury, puncture wounds, lacerations, fractures, or tendon damage.

Although infection is possible, the infection rate is generally lower than that associated with cat bites.

Human Bites

Human bite injuries are less common than animal bites, and their true incidence is difficult to determine.

Some patients with fight bites do not initially disclose that the injury occurred during an altercation, which can delay diagnosis and appropriate treatment.

Risk Factors

Risk factors include alcohol misuse, fighting, exposure to unfamiliar animals, and delayed presentation for treatment.

Cat bites have a particularly high risk of infection because their sharp, narrow teeth can penetrate deeply into tissue.

Approximately 30–50% of cat bites may become infected, whereas dog bites have a lower infection rate.

Etiology

Common mechanisms include fistfights, dog bites, cat bites, and bites from other mammals.

The mechanism is important because different bite types cause different patterns of tissue damage and expose the patient to different organisms.

Associated Injuries

Hand bites may be associated with fractures, extensor tendon lacerations, joint capsule penetration, and retained foreign material such as tooth fragments.

Infectious complications may include cellulitis, abscess formation, septic tenosynovitis, septic arthritis, osteomyelitis, and systemic sepsis.

Diagnosis

Signs and Symptoms

The most obvious finding is usually a puncture wound or laceration of the hand.

Swelling and erythema may develop around the injury.

If infection occurs, cellulitis or lymphangitis may spread beyond the original wound.

Tendon Injury

If the extensor tendon has been injured, the patient may have difficulty extending the affected finger.

However, apparent finger extension does not completely exclude extensor injury because the intrinsic muscles can sometimes extend the proximal interphalangeal joint even when part of the extensor mechanism has been disrupted.

Symptoms

Patients may report pain at the wound, along the affected digit or ray, or around the adjacent MCP joint.

Hand function may be reduced, with difficulty gripping objects or moving an individual finger.

Pain and swelling that progressively worsen after the initial injury suggest developing infection.

History

The history should identify whether the wound resulted from a human bite, animal bite, or clenched-fist impact against another person’s mouth.

The clinician should ask about increasing erythema, swelling, pain, drainage, fever, and reduced hand function.

Immunocompromising conditions should also be identified because they increase the risk and severity of infection.

Delayed Presentation

Patients with clenched-fist injuries may minimize or conceal how the injury occurred.

Some may also fail to appreciate the seriousness of a small dorsal hand wound.

Delayed presentation is associated with a higher rate of infection, tissue destruction, joint damage, and poor functional outcome.

Physical Examination

The hand should be examined carefully for every puncture or laceration.

Special attention should be paid to wounds over the third and fourth MCP joints, which are common locations for clenched-fist injuries.

Even a small wound in this area should be considered potentially deep until proven otherwise.

Neurovascular Examination

Motor, sensory, and vascular function should be assessed in the entire hand and in each individual digit.

Capillary refill, pulse examination when appropriate, sensation, and active movement should be documented before treatment.

Examination in the Injured Position

When a clenched-fist injury is suspected, the patient should be asked to make a fist if tolerated.

Flexing the MCP joint may realign the superficial wound with the underlying tendon or joint injury and improve visualization of the true depth of penetration.

Extensor Mechanism Assessment

The extensor tendons should be examined carefully.

Because the intrinsic muscles can contribute to extension of the proximal interphalangeal joint, a patient may appear to have preserved extension despite injury to the central slip or more proximal extensor tendon.

Individual tendon function should therefore be tested systematically.

Laboratory Tests

Laboratory evaluation may include a white blood cell count, erythrocyte sedimentation rate, and C-reactive protein when infection is suspected.

These tests can assist in assessing and monitoring inflammatory activity but do not replace clinical examination.

Wound Cultures

When operative debridement is required, cultures should preferably be obtained from deep tissue specimens rather than superficial swabs.

Tissue cultures generally provide more meaningful information regarding the causative organisms.

Imaging

Plain Radiographs

Radiographs of the hand should be obtained when a significant bite injury is suspected.

They can identify fractures, bone impaction, retained tooth fragments, or other foreign bodies.

Delayed Imaging Findings

In patients presenting later, radiographs may demonstrate changes associated with osteomyelitis.

Bone destruction, periosteal reaction, or other abnormalities may indicate progression of infection beyond the soft tissues.

Ultrasound

Ultrasound can be useful for detecting fluid collections or abscesses.

It may also assist in evaluating selected soft-tissue abnormalities when the physical examination is uncertain.

Differential Diagnosis

The differential diagnosis includes a simple superficial laceration and a retained foreign body.

However, apparently minor wounds over the MCP joint after an altercation should always raise concern for deeper bite injury.

Treatment

Tetanus Prophylaxis

Tetanus immunization status should be reviewed in every patient.

If immunization is not up to date, appropriate tetanus-containing vaccination should be administered.

Patients with an incomplete prior vaccination series may also require tetanus immune globulin, depending on the wound and immunization history.

Rabies Considerations

Rabies exposure should be assessed according to the animal involved and the circumstances of the bite.

In the United States, rabies is most commonly associated with animals such as bats, raccoons, skunks, and foxes.

When significant exposure has occurred and the animal cannot immediately be confirmed to be free of rabies, appropriate post-exposure prophylaxis should be considered.

Irrigation and Debridement

The most important early treatment is aggressive irrigation and debridement.

The goal is to remove bacteria, devitalized tissue, contaminated material, and retained foreign bodies.

Copious irrigation with normal saline is commonly performed initially.

Wound Exploration

The wound may need to be extended surgically to determine its true depth.

In clenched-fist injuries, careful exploration is particularly important to assess the extensor tendon, joint capsule, cartilage, and MCP joint.

Failure to identify joint penetration can result in septic arthritis.

Wound Management

After adequate irrigation and debridement, deeper structures may be loosely covered as necessary.

The wound is generally left open rather than primarily sutured, particularly when contamination or infection is present.

Packing and regular dressing changes may be used depending on the wound.

Immobilization and Elevation

The hand should initially be immobilized and elevated.

This decreases soft-tissue stress, swelling, and pain while the acute wound is being monitored.

Prolonged immobilization should be avoided once the infection is controlled because stiffness can develop rapidly.

Antibiotic Prophylaxis

Because hand bites carry a substantial infection risk, prophylactic antibiotics are generally recommended.

Amoxicillin-clavulanate is commonly used as a first-line oral agent when the patient is not allergic.

A typical prophylactic course lasts approximately 5–7 days, depending on the injury and clinical circumstances.

Follow-Up After Initial Treatment

The wound should be reassessed early, commonly within approximately 24 hours.

If packing has been used, it can be removed or changed at this visit.

Warm soaks and local wound care may then be initiated when appropriate.

Management of Established Infection

If infection is present, repeat irrigation and debridement may be necessary.

Patients with significant infection may require hospital admission and intravenous antibiotic therapy.

Septic arthritis, deep-space infection, tendon sheath infection, or systemic illness requires particularly aggressive management.

Physical Therapy

Formal therapy is usually unnecessary during the immediate acute phase.

However, once the wound is stable and infection is controlled, finger range-of-motion exercises should begin relatively early, often within the first week.

Early motion helps prevent stiffness, particularly at the MCP joints.

Common Organisms in Human Bites

The human mouth contains numerous bacterial species.

Common organisms associated with human bite wounds include Eikenella corrodens and streptococcal species, along with staphylococci and anaerobic organisms.

Because the flora are polymicrobial, antibiotic coverage should address both aerobic and anaerobic bacteria.

Common Organisms in Animal Bites

Animal bite infections may involve Pasteurella species, Staphylococcus aureus, streptococci, Bacteroides, and other anaerobic organisms.

Pasteurella is particularly associated with cat and dog bites.

First-Line Oral Antibiotic

Amoxicillin-clavulanate provides broad coverage against many organisms encountered in both human and animal bites.

It is therefore commonly selected as first-line oral therapy in patients who can tolerate penicillin-class antibiotics.

Intravenous Antibiotics

Clinically apparent deep infection may require intravenous therapy.

An agent such as ampicillin-sulbactam may be used empirically before culture results are available.

Treatment should subsequently be adjusted according to culture and sensitivity results.

Blood-Borne Viral Transmission

Although uncommon, human bites involving blood exposure can potentially transmit hepatitis B, hepatitis C, or HIV.

The risk depends on whether blood was present in the mouth or wound and on the infectious status of the individuals involved.

Appropriate exposure assessment should therefore be performed when significant blood contact has occurred.

Hepatitis B Prophylaxis

Hepatitis B vaccination status should be reviewed after a human bite involving blood exposure.

An accelerated vaccination schedule or other post-exposure measures may be considered according to the patient’s immunity and exposure risk.

Surgical Management

Surgical irrigation and debridement involve removing contaminated and nonviable tissue and thoroughly cleaning infected spaces.

All potentially involved structures should be assessed during exploration.

Joint Involvement

If the joint capsule has been penetrated, formal joint irrigation and debridement are required.

This is essential to reduce the risk of septic arthritis and subsequent cartilage destruction.

Cultures During Surgery

Deep cultures should be obtained intraoperatively before definitive antibiotic adjustment whenever possible.

Tissue specimens are preferred because they more accurately represent the organisms responsible for deep infection.

Wound Closure

Bite wounds requiring operative treatment are generally left open and managed with dressing changes rather than closed primarily.

Delayed closure may be considered later when contamination and infection have resolved.

Tendon Reconstruction

Extensor tendon injuries or other structures requiring definitive reconstruction are often not repaired immediately if active infection is present.

The initial priority is controlling infection.

Definitive tendon repair or reconstruction can be addressed after the wound has become clean and infection has resolved.

Follow-Up

Close follow-up is essential.

The wound should be reassessed early to ensure that swelling, erythema, pain, and drainage are improving rather than worsening.

Hand function and neurovascular status should also be monitored.

Prognosis

The prognosis is generally good when bite injuries are recognized and treated early.

Prompt irrigation, debridement, antibiotics, and appropriate follow-up can prevent most serious complications.

Late presentation substantially worsens the prognosis.

Delayed Presentation

Patients presenting very late, particularly after more than approximately 8 days, have a higher risk of severe infection, tissue loss, joint destruction, and even amputation.

This emphasizes the importance of early recognition and treatment.

Complications

The most important complication is infection, which may involve the soft tissues, tendon sheaths, joints, or bone.

Other complications include stiffness, persistent pain, tendon injury, loss of motion, and reduced hand function.

Septic Arthritis

Penetration of a bite wound into the MCP joint may result in septic arthritis.

Without prompt treatment, infection can rapidly damage the articular cartilage and lead to chronic pain, stiffness, and loss of function.

Osteomyelitis

Untreated or delayed infection can spread into bone and produce osteomyelitis.

This complication may require prolonged antibiotic treatment and additional surgical debridement.

Stiffness

Hand stiffness may develop because of pain, edema, infection, prolonged immobilization, or tendon and joint injury.

Early supervised range-of-motion exercises are therefore important once the wound is sufficiently stable.

Patient Monitoring

If packing is used, it should generally be removed or changed at approximately 24 hours.

The patient should continue to be followed until the wound is healing satisfactorily and there is no evidence of progressive infection.

When there is uncertainty regarding wound stability or infection, reassessment at 24–48-hour intervals is appropriate.

Orthopaedic Surgery - Bisphosphonates

Basics

Bisphosphonates are medications that reduce bone resorption by suppressing osteoclast activity.

They are commonly used in the treatment of osteoporosis, metastatic bone disease, Paget disease of bone, and malignancy-associated hypercalcemia.

Bisphosphonates can be administered either orally or intravenously, depending on the clinical indication, patient factors, and specific medication being used.

Oral Bisphosphonates

Commonly used oral bisphosphonates include alendronate, risedronate, and ibandronate.

These agents are frequently prescribed for osteoporosis and other conditions characterized by excessive bone turnover.

Because oral bisphosphonates can irritate the upper gastrointestinal tract, specific administration instructions are important.

Intravenous Bisphosphonates

Frequently used intravenous agents include zoledronate and pamidronate.

Intravenous therapy is particularly useful in patients with metastatic bone disease, multiple myeloma, malignancy-related hypercalcemia, or those who cannot tolerate oral treatment.

Epidemiology and Clinical Use

Patients with metastatic bone disease or multiple myeloma often have increased osteoclast-mediated bone destruction.

As a result, most such patients receive therapy that suppresses osteoclast function, either with a bisphosphonate or another antiresorptive agent such as denosumab, which inhibits osteoclast formation, function, and survival.

High Bone-Turnover Disorders

Bisphosphonates are also commonly used in disorders associated with increased bone turnover.

These include osteoporosis, Paget disease, and selected cases of polyostotic fibrous dysplasia.

By reducing osteoclastic activity, these medications can decrease excessive bone resorption and improve skeletal stability.

Risk Factors and Dental Considerations

One of the most important concerns before starting bisphosphonate therapy is poor dental health.

Patients with significant dental disease may be at greater risk of developing osteonecrosis of the jaw, particularly when potent intravenous bisphosphonates are used for prolonged periods.

Pretreatment Dental Evaluation

Before beginning long-term or high-potency bisphosphonate therapy, patients should undergo appropriate dental evaluation.

Any necessary tooth extractions, treatment of active dental infection, or major reconstructive dental procedures should ideally be addressed before therapy begins.

Good oral hygiene and regular dental follow-up remain important during treatment.

Pathophysiology

Bisphosphonates reduce skeletal resorption by interfering with the normal function and survival of osteoclasts, the cells responsible for breaking down bone.

Their action ultimately decreases the rate at which mineralized bone is removed.

Mevalonate Pathway

Many bisphosphonates act by interfering with enzymes in the mevalonate pathway.

Disruption of this pathway impairs intracellular processes required for normal osteoclast function.

This reduces the ability of osteoclasts to adhere to and resorb bone effectively.

Osteoclast Ruffled Border

Active osteoclasts form a specialized ruffled border against the bone surface.

This structure is essential for creating the acidic environment and releasing enzymes required for bone resorption.

Bisphosphonates interfere with this resorptive apparatus and thereby diminish osteoclastic activity.

Osteoclast Apoptosis

Bisphosphonates can also promote apoptosis, or programmed cell death, of osteoclasts.

The resulting reduction in osteoclast number and activity decreases bone turnover and limits further bone loss.

Complications

The adverse effects of bisphosphonate therapy vary according to whether the medication is administered orally or intravenously and according to treatment duration.

Important complications include gastrointestinal irritation, acute systemic reactions, osteonecrosis of the jaw, and atypical femoral fractures.

Gastrointestinal Adverse Effects

The most common complication of oral bisphosphonate therapy is upper gastrointestinal irritation or gastric upset.

Patients may experience dyspepsia, reflux symptoms, esophageal irritation, or abdominal discomfort.

Proper administration helps reduce these complications.

Administration of Oral Bisphosphonates

Oral bisphosphonates should generally be taken on an empty stomach with a full glass of water.

The patient should remain upright after taking the medication, traditionally for approximately 30–60 minutes depending on the specific preparation, to reduce the risk of esophageal irritation.

Food and other medications may interfere with absorption and should be avoided for the recommended period after dosing.

Intravenous Adverse Effects

The most common early adverse effects of intravenous bisphosphonates include fever, bone pain, and muscle aches.

These acute-phase reactions may occur in approximately one-quarter of patients, particularly after an initial infusion.

Symptoms are usually temporary.

Osteonecrosis of the Jaw

One of the most important long-term complications of bisphosphonate therapy is osteonecrosis of the jaw.

This complication is characterized by impaired healing and exposed or necrotic jaw bone, often after dental extraction or other invasive dental treatment.

The risk is particularly relevant in patients receiving high-dose intravenous therapy for malignancy.

Prevention of Jaw Osteonecrosis

Preventive measures include addressing major dental problems before treatment, maintaining good oral hygiene, and obtaining regular dental care.

Patients should inform their dentist that they are receiving bisphosphonate therapy.

Any invasive dental procedure during treatment should be planned carefully.

Atypical Femoral Fractures

Long-term bisphosphonate use is also associated with atypical stress fractures of the femur.

These fractures commonly involve the subtrochanteric or femoral shaft region and may develop gradually because of prolonged suppression of bone remodeling.

Prodromal Symptoms

Before an atypical femoral fracture becomes complete, patients may experience thigh or groin pain during walking or weight-bearing.

This discomfort may precede fracture by weeks or months.

Patients receiving prolonged bisphosphonate therapy should report new persistent thigh or groin pain promptly.

Radiographic Findings

Early radiographs may be normal.

When abnormalities are present, they may include periosteal reaction, cortical thickening, or localized beaking of the lateral femoral cortex.

These findings can represent an incomplete or impending atypical fracture.

Duration of Therapy

Because the risk of atypical femoral fracture increases with prolonged treatment, the need for continued bisphosphonate therapy should be reassessed periodically.

Long-term treatment should be individualized according to the patient’s fracture risk, response to therapy, and potential complications rather than continued automatically.

Drug Holiday Consideration

In selected patients whose fracture risk has fallen after several years of therapy, a temporary bisphosphonate drug holiday may be considered.

The timing and duration depend on the specific medication, bone density, previous fractures, and overall osteoporosis risk.

Patients at very high fracture risk may require continued therapy or an alternative treatment strategy.

Patient Monitoring

Patients receiving bisphosphonates are commonly monitored with serial dual-energy X-ray absorptiometry (DEXA) scans.

DEXA testing provides an estimate of bone mineral density and helps assess the response to osteoporosis treatment over time.

Additional Monitoring

Follow-up should also include assessment for new fractures, changes in height or posture, medication tolerance, dental problems, and symptoms suggestive of atypical femoral fracture.

Persistent thigh or groin pain should prompt further evaluation even when the initial radiograph is normal.

Patient Education

Patients should understand why bisphosphonate therapy has been prescribed and how to take the medication correctly.

Those receiving oral therapy should follow administration instructions carefully to reduce gastrointestinal complications.

Patients should also maintain good dental care and promptly report jaw symptoms, persistent thigh or groin pain, or other new skeletal complaints.

Prognosis

When used appropriately, bisphosphonates can substantially reduce excessive bone resorption and help lower fracture risk in patients with osteoporosis and other high-turnover skeletal disorders.

The benefits of therapy should be balanced against uncommon but potentially important complications, especially during prolonged treatment.

Regular reassessment allows treatment to be adjusted according to changing fracture risk and patient response.

Orthopaedic Surgery - Biceps Tendon Rupture

Basics

The biceps tendon may rupture either proximally near the shoulder or distally near the elbow.

Most biceps tendon ruptures occur proximally.

At the shoulder, the long head of the biceps contributes to stabilization and depression of the humeral head. Distally, the biceps is the principal supinator of the forearm and also contributes significantly to elbow flexion.

Epidemiology

Biceps tendon rupture occurs most commonly in men between 40 and 60 years of age.

The dominant upper extremity is affected more frequently.

Although the condition is classically seen in middle-aged adults, rupture can also occur in younger athletes. In younger individuals, a history of anabolic steroid use should be considered because steroid exposure may weaken tendon structure.

Risk Factors

Important risk factors include male sex, age between 40 and 60 years, tendon degeneration, and anabolic steroid use.

For proximal ruptures, associated rotator cuff impingement or rotator cuff disease increases the risk of tendon failure.

For distal ruptures, chronic degenerative changes within the tendon predispose it to avulsion during a sudden high-load eccentric contraction.

Pathophysiology

Most biceps tendon ruptures occur through a background of degenerative tendon change.

This degeneration may be symptomatic or may remain clinically silent until rupture occurs.

In the proximal tendon, degeneration may result from reduced vascularity or chronic mechanical impingement beneath the coracoacromial arch.

Distal Tendon Pathophysiology

The distal biceps tendon commonly fails near its attachment to the radial tuberosity.

A degenerated tendon may avulse when subjected to a sudden and powerful eccentric force, particularly when the elbow is flexed and the muscle is attempting to contract against resistance.

This mechanism is often seen when a person suddenly tries to hold or lower a heavy object.

Associated Conditions

Biceps tendon rupture is commonly associated with rotator cuff disease, particularly when the rupture is proximal.

The presence of associated shoulder pathology should therefore be assessed during evaluation.

Diagnosis

Signs and Symptoms

Symptoms depend on whether the rupture is proximal or distal.

A sudden tearing sensation may be followed by pain, bruising, swelling, weakness, and visible change in the contour of the biceps muscle.

History in Proximal Rupture

Patients with a proximal biceps tendon rupture may complain of pain in the anterior shoulder, upper arm, or antecubital region.

Pain may be acute initially but can improve relatively quickly.

Some patients primarily notice a change in arm appearance rather than major functional loss.

History in Distal Rupture

Patients with a distal rupture commonly report antecubital pain together with weakness during forearm supination or elbow flexion.

The injury often follows a clear history of a sudden heavy eccentric load applied to a contracting biceps muscle.

Patients may describe a pop or tearing sensation at the time of injury.

Physical Examination

Proximal Rupture

Proximal tears may produce bruising and swelling around the shoulder, arm, or antecubital fossa.

The biceps muscle belly may retract distally, creating an abnormal contour of the arm.

This can produce the characteristic “Popeye” deformity.

Distal Rupture

With a distal tendon rupture, the biceps muscle belly retracts proximally toward the shoulder.

The normal tendon may no longer be palpable in the antecubital fossa.

A clearly absent distal tendon strongly suggests a complete distal rupture.

Strength Testing

Weakness may be present with both elbow flexion and forearm supination.

The loss of strength is usually more clinically significant after a distal rupture because the distal biceps plays a major role in supination.

Pain during resisted flexion or supination may occur in partial tears.

Popeye Sign

The Popeye sign describes visible bunching or distortion of the biceps muscle belly after tendon rupture.

It is more classically associated with proximal long-head biceps rupture, although changes in muscle contour may also occur with distal injury.

The location of muscle retraction helps distinguish proximal from distal rupture.

Imaging

MRI

MRI is the most useful imaging study when the diagnosis is uncertain or when the extent of injury must be defined.

It can identify complete or partial tendon disruption, tendon retraction, associated rotator cuff pathology, and surrounding soft-tissue injury.

MRI is particularly useful for planning surgery in distal ruptures or symptomatic partial tears.

Differential Diagnosis

Important differential diagnoses include rotator cuff impingement and rotator cuff tear.

Other causes of shoulder or antecubital pain should also be considered when the examination does not clearly demonstrate tendon rupture.

Treatment

General Principles

Management depends primarily on whether the rupture is proximal or distal, as well as the patient’s age, activity level, functional demands, cosmetic concerns, and associated pathology.

Proximal ruptures are often successfully treated nonoperatively.

Distal ruptures are more commonly treated surgically because untreated injury can result in meaningful loss of strength.

Proximal Biceps Tendon Rupture

Initial treatment of an isolated proximal rupture is usually nonoperative.

Many affected patients are older than 40 years and experience only modest weakness or functional limitation.

Pain often settles with conservative care, and many patients adapt well to the cosmetic deformity.

Candidates for Surgery After Proximal Rupture

Surgical treatment may be considered in patients who are younger, highly active, athletic, concerned about the appearance of the arm, or seeking maximal restoration of function.

Persistent cramping or pain may also support operative treatment.

Distal Biceps Tendon Rupture

For complete distal ruptures, surgical repair generally provides the best functional outcome, particularly in active patients.

Because the distal biceps is an important supinator, nonoperative treatment can result in persistent weakness, especially during activities requiring forceful supination.

Partial Distal Rupture

Partial distal biceps tears may initially be treated nonoperatively when symptoms are mild.

However, persistent pain or weakness despite conservative management may require surgical treatment.

Operative management may involve completing the partial release and then repairing the tendon back to the radial tuberosity.

Nonoperative Management

Conservative treatment includes rest, activity modification, analgesia, and gradual rehabilitation.

During the acute phase, the arm should be rested until pain and swelling decrease.

Gentle range-of-motion exercises can then begin.

Activity is gradually advanced as tolerated.

Physical Therapy

Physical therapy focuses initially on maintaining comfortable shoulder, elbow, and forearm motion.

As pain improves, strengthening can be introduced progressively.

In nonoperatively treated patients, rehabilitation aims to maximize the function of remaining muscles and compensate for any persistent weakness.

Medication

NSAIDs and acetaminophen may be used during the acute phase for pain relief.

Medication should be combined with rest and gradual restoration of function.

Surgical Management of Proximal Rupture

For selected proximal ruptures, the biceps tendon may be treated with tenodesis.

In this procedure, the tendon is fixed to the humerus to restore a more normal muscle contour and reduce cramping or discomfort.

Tenodesis is often performed mainly for functional or cosmetic reasons.

Proximal Rupture With Rotator Cuff Disease

When a proximal biceps rupture occurs together with significant rotator cuff or impingement pathology, surgery may address both conditions.

Procedures may include biceps tenodesis together with treatment of rotator cuff disease, and in selected cases acromioplasty may also be performed.

Surgical Management of Distal Rupture

Distal biceps repair involves reattaching the tendon to the radial tuberosity.

This can be performed through a single anterior incision or through a two-incision muscle-splitting approach.

The objective is to restore the normal insertion and regain elbow flexion and forearm supination strength.

Surgery for Symptomatic Partial Tears

A symptomatic partial distal tear may be treated surgically when pain or weakness persists.

The damaged tendon may be released and then formally reattached to the radial tuberosity.

This can improve both pain and function in appropriately selected patients.

Follow-Up

Follow-up should assess pain, swelling, range of motion, strength, and restoration of functional use of the arm.

Patients treated surgically require progressive rehabilitation according to tendon healing and the repair technique used.

Strengthening should be advanced carefully to protect the repair.

Prognosis

Patients undergoing successful surgical repair of a distal biceps rupture can generally expect a near-complete return of flexion and supination strength.

Outcome is typically best when repair is performed before substantial chronic retraction or scarring develops.

Prognosis After Proximal Tenodesis

Patients undergoing tenodesis for a proximal rupture can generally expect good pain relief and improvement in arm contour.

The procedure also helps reduce the prominence of the Popeye deformity.

Complications of Nonoperative Treatment

Without surgery, some patients may continue to experience activity-related pain, cramping, or weakness.

This is usually more clinically important after distal rupture than proximal rupture.

Loss of Supination Strength

The most important functional deficit after an untreated distal biceps rupture is reduced forearm supination strength.

Patients may notice difficulty with activities such as turning a screwdriver, opening a jar, using tools, or performing repetitive lifting with the palm facing upward.

Elbow flexion strength may also decrease, but the loss is generally less pronounced because other muscles can assist with flexion.

Patient Monitoring

Patients should be monitored for recovery of pain-free motion, strength, and functional use of the extremity.

Persistent weakness, ongoing pain, or difficulty with supination should prompt reassessment, particularly in patients with suspected distal rupture or symptomatic partial tendon injury.

Orthopaedic Surgery - Back Pain in Children

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Basics

Pediatric back pain is less common than back pain in adults but becomes increasingly frequent with age.

The estimated prevalence is approximately 6% among children aged 7–10 years and approximately 18% among adolescents aged 14–16 years.

Participation in competitive sports has been associated with a higher risk of pediatric back pain. Behavioral, emotional, and psychological difficulties may also be associated with a greater frequency of symptoms.

Although most pediatric back pain is musculoskeletal and self-limiting, persistent or severe symptoms require careful evaluation because infection, tumor, structural abnormalities, and neurologic disorders may also present with back pain.

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Etiology

The differential diagnosis of pediatric back pain is broad.

Important causes include spondylolysis, spondylolisthesis, tethered cord syndrome, neoplasms, spondyloarthropathies, Bertolotti syndrome, discitis, pyogenic sacroiliitis, Scheuermann disease, lumbar disc herniation, and musculoskeletal strain.

Age, pain characteristics, neurologic findings, systemic symptoms, and activity history help distinguish among these conditions.

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Spondylolysis

Spondylolysis is a defect or stress fracture involving the pars interarticularis, the portion of the vertebral arch located between the superior and inferior facet joints.

It usually develops as a fatigue injury caused by repeated lumbar extension and rotational movements.

Sports involving repetitive hyperextension, such as gymnastics and certain throwing or kicking activities, can increase mechanical stress on the pars.

The estimated prevalence in children is approximately 4.4%.

The fifth lumbar vertebra (L5) is affected most commonly.

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Spondylolisthesis

Spondylolisthesis refers to anterior displacement of one vertebral body relative to the vertebra beneath it.

In children and adolescents, it frequently occurs in association with a pars defect or spondylolysis.

Its estimated prevalence is approximately 0.9%.

Low back pain is the most common clinical manifestation, although some patients may also develop radicular pain or neurologic symptoms if neural structures are affected.

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Primary Tethered Cord Syndrome

Primary tethered cord syndrome is caused by abnormal fixation of the lower spinal cord to surrounding tissues.

This abnormal attachment restricts normal movement of the cord during growth and may progressively impair the lumbosacral nerve roots.

The estimated prevalence is approximately 0.1%.

Tethered cord syndrome may occur together with other congenital spinal abnormalities, including spina bifida.

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Clinical Features of Tethered Cord Syndrome

Symptoms may include low back pain, lower-extremity muscle wasting, clubfoot deformity, leg-length discrepancy, scoliosis, weakness, and sensory loss.

Bladder or bowel dysfunction may also occur in clinically significant cases.

Progressive neurologic abnormalities should prompt further spinal cord evaluation.

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Neoplastic Causes

Tumors are a rare cause of pediatric back pain, accounting for approximately 0.1% of cases.

Both benign and malignant bone or spinal cord tumors may present with back pain.

Pain that is persistent, occurs at night, is associated with systemic symptoms, or is accompanied by neurologic abnormalities warrants further investigation.

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Osteoid Osteoma

An osteoid osteoma is a benign primary bone tumor that may involve the spine.

Up to approximately 20% of osteoid osteomas can occur in spinal locations.

A characteristic clinical feature is back or neck pain that is worse at night and responds markedly to NSAIDs.

The lesion may also cause painful scoliosis when located asymmetrically in the posterior spinal elements.

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Ewing Sarcoma

Ewing sarcoma is an important malignant bone tumor occurring in children and adolescents.

It may present with localized pain together with systemic or constitutional symptoms such as fever, fatigue, and weight loss.

Persistent unexplained back pain associated with constitutional symptoms should therefore raise concern for malignancy.

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Spinal Cord Tumors

Spinal cord tumors may be benign or malignant.

Clinical manifestations depend on the location and extent of the lesion.

Children may develop back pain, progressive motor weakness, sensory abnormalities, gait disturbance, or bowel and bladder dysfunction.

Neurologic deterioration requires prompt imaging.

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Spondyloarthropathies

Pediatric spondyloarthropathies include ankylosing spondylitis, psoriatic arthritis, enthesitis-related arthritis, reactive arthritis, and arthritis associated with inflammatory bowel disease.

Their estimated prevalence is approximately 0.2%.

Common manifestations include inflammatory back pain, sacroiliitis, enthesitis, and dactylitis.

Many affected children are HLA-B27 positive, although HLA-B27 positivity alone does not establish the diagnosis.

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Associated Features of Spondyloarthropathies

Reactive arthritis may occur in association with urethritis and conjunctivitis.

Psoriatic arthritis may be associated with cutaneous or nail manifestations of psoriasis.

Enteropathic arthritis occurs in association with inflammatory bowel disease.

Recognition of these associated features can help identify an inflammatory cause of back pain.

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Bertolotti Syndrome

Bertolotti syndrome occurs when a lumbosacral transitional vertebra becomes symptomatic.

A lumbosacral transitional vertebra is an anatomical variant in which the lowest lumbar vertebra has an enlarged transverse process that partially or completely articulates or fuses with the sacrum.

The estimated prevalence of this anatomical variant is approximately 4–10%.

When the abnormal articulation is responsible for low back pain, the condition is termed Bertolotti syndrome.

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Clinical Features of Bertolotti Syndrome

Pain is commonly mechanical and may worsen during lumbar extension.

Some patients also develop radicular symptoms caused by altered lumbosacral mechanics or nerve compression.

Radiographs may demonstrate an enlarged transverse process articulating with the sacrum.

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Discitis

Discitis is an inflammatory or infectious disorder of the intervertebral disc space and is seen most commonly in children younger than approximately 5 years.

Young children may present with back pain, irritability, refusal to walk, or reluctance to sit or bend.

Many affected children remain afebrile, and the peripheral white blood cell count may be normal.

The erythrocyte sedimentation rate (ESR) is elevated in many cases and can support the diagnosis.

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Pyogenic Sacroiliitis

Pyogenic sacroiliitis is a bacterial infection involving the sacroiliac joint.

Patients may complain of pain in the lower back, buttock, hip, or abdomen.

The ESR is often elevated, although the white blood cell count may remain normal.

Because symptoms may be poorly localized, diagnosis can be delayed without a high index of suspicion.

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Scheuermann Disease

Scheuermann disease is a developmental disorder involving the thoracic or thoracolumbar vertebrae.

Its estimated prevalence is approximately 0.2%.

The classic radiographic criterion is anterior wedging greater than 5° in at least three consecutive vertebral bodies.

The precise cause is uncertain, although a hereditary component with autosomal dominant inheritance and incomplete penetrance has been proposed.

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Clinical Features of Scheuermann Disease

Patients commonly present during adolescence with back pain and a rigid focal kyphotic deformity.

Pain may worsen with prolonged sitting, standing, or activity.

Unlike postural kyphosis, the deformity is relatively rigid and does not fully correct with voluntary posture.

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Herniated Nucleus Pulposus

Lumbar disc herniation is uncommon in younger children but may occur in adolescents, sometimes after trauma.

The lumbar spine is affected most frequently.

Symptoms often include low back pain radiating into one or both lower extremities, depending on the nerve root involved.

Neurologic deficits may develop when compression is substantial.

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Musculoskeletal Back Pain

Muscular strain and ligamentous sprain are the most common causes of pediatric back pain.

Symptoms are generally related to activity and improve with rest.

Musculoskeletal back pain is typically self-limiting.

When the history and examination are reassuring and no red-flag features are present, additional imaging may not be necessary.

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Diagnosis

History

History should focus on defining the location, quality, severity, duration, and pattern of pain.

The clinician should ask about trauma, sports participation, repetitive activities, aggravating movements, and previous episodes.

Particular attention should be paid to features that suggest more serious pathology.

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Concerning Symptoms

Red-flag symptoms include motor or sensory deficits, persistent nocturnal pain, bowel or bladder dysfunction, progressive weakness, and gait disturbance.

Constitutional symptoms such as fever, unexplained weight loss, and fatigue may suggest infectious, inflammatory, or neoplastic disease.

These findings usually warrant further investigation.

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Psychological Assessment

Mental and emotional well-being should also be considered.

Anxiety, depression, behavioral problems, and emotional distress have been associated with a higher prevalence of pediatric back pain.

These factors should be evaluated without assuming that the pain is purely psychological.

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Physical Examination

A complete examination should include inspection, palpation, provocative maneuvers, lumbar range of motion, gait assessment, and a detailed neurologic examination.

The findings should be interpreted together with the history.

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Inspection

The child’s posture should be evaluated in both the coronal and sagittal planes.

The examiner should look for scoliosis, excessive kyphosis, abnormal lordosis, pelvic asymmetry, or other deformity.

Skin findings such as dimples, hairy patches, masses, or other congenital markers over the spine may suggest occult spinal dysraphism.

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Gait Assessment

Gait should be observed for abnormalities such as Trendelenburg gait, limping, weakness, or ataxia.

An abnormal gait may indicate hip pathology, neurologic dysfunction, pain, or muscular weakness.

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Palpation

The spinal column, paraspinal muscles, and sacroiliac joints should be palpated.

Midline spinal tenderness raises concern for fracture, infection, or other structural pathology.

Paraspinal tenderness is more commonly associated with muscular strain.

The examiner should also assess for swelling, edema, or a palpable mass.

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Straight Leg Raise Test

The straight leg raise test helps assess possible lumbar disc herniation with nerve root irritation.

With the patient lying supine, the examiner passively raises the leg while maintaining the knee in extension.

Reproduction of radicular pain when the hip is flexed approximately 30–70° supports irritation of the lumbosacral nerve roots and raises suspicion for disc herniation.

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FABER Test

The FABER test evaluates pathology involving the sacroiliac joint or hip.

With the patient supine, the tested hip is flexed, abducted, and externally rotated so that the ankle rests over the opposite thigh.

Downward pressure is then applied to the flexed knee while the contralateral pelvis is stabilized.

Pain around the sacroiliac region may suggest SI joint pathology, including sacroiliitis.

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Lumbar Range of Motion

Lumbar range of motion does not always identify the specific cause of pain, but it can help assess functional limitation and disease progression.

Average pediatric lumbar flexion is approximately 52°, with extension around 19°.

Average axial rotation is approximately 33° to the left and 32° to the right.

Average lateral flexion is approximately 30° to the left and 31° to the right.

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Neurologic Examination

A detailed bilateral neurologic examination should assess motor strength, sensation, and reflexes.

Neurologic abnormalities may help localize a disc herniation or identify spinal cord or nerve root pathology.

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Disc Herniation Findings

An L4–L5 disc herniation may cause weakness involving ankle or great-toe dorsiflexion, depending on the affected nerve root.

An L5–S1 disc herniation may produce a diminished or absent Achilles tendon reflex.

Sensory changes should also be mapped according to the involved dermatome.

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Neurologic Red Flags

Progressive weakness, abnormal reflexes, sensory loss, gait disturbance, or bowel and bladder dysfunction should raise concern for significant neurologic compression or a spinal cord lesion.

Neoplastic and congenital neurologic disorders must also be considered.

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Imaging

The three principal imaging modalities are plain radiographs, CT, and MRI.

The decision to image should be based on the patient’s symptoms and examination while considering radiation exposure and the possible need for sedation in younger children.

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When Imaging Is Not Required

When the neurologic examination is normal and there are no concerning features such as fever, weight loss, persistent night pain, or neurologic changes, immediate imaging is often unnecessary.

Children with uncomplicated musculoskeletal pain may be managed initially with observation and conservative care.

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Plain Radiographs

Plain radiographs are often the initial imaging study when structural pathology is suspected.

They are useful for evaluating vertebral alignment, deformity, spondylolysis, spondylolisthesis, transitional vertebrae, Scheuermann disease, and some tumors.

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CT

CT provides excellent visualization of bone detail.

It can help define pars defects, fractures, congenital abnormalities, and other osseous lesions.

Three-dimensional reconstructions can be useful when detailed anatomical assessment is required.

Because CT exposes children to ionizing radiation, its use should be selective.

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MRI

MRI provides detailed visualization of the spinal cord, nerve roots, intervertebral discs, bone marrow, ligaments, and soft tissues.

It is particularly useful for evaluating infection, tumors, tethered cord, disc herniation, sacroiliitis, and neurologic abnormalities.

MRI avoids ionizing radiation but may require sedation in some young children.

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Imaging in Spondylolysis

Plain radiographs may demonstrate a radiolucent defect through the pars interarticularis.

When radiographs are normal but clinical suspicion remains high, advanced imaging may be considered.

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Imaging in Spondylolisthesis

Radiographs demonstrate anterior displacement of one vertebral body relative to the vertebra below.

Standing lateral radiographs are particularly useful for assessing the degree of slip.

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Imaging in Tethered Cord Syndrome

MRI is the preferred study.

Findings may include abnormalities of the filum terminale, a low-lying cord, or dorsal adherence of the spinal cord.

Associated congenital abnormalities may also be identified.

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Imaging in Osteoid Osteoma

Radiographs or CT may demonstrate a small focal lesion, often with surrounding sclerosis.

CT is particularly useful for identifying the central nidus when osteoid osteoma is suspected.

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Imaging in Ewing Sarcoma

Radiographs may show a destructive bone lesion with a mixture of lytic and sclerotic features.

MRI is useful for defining marrow involvement and soft-tissue extension.

Further oncologic imaging is required if malignancy is suspected.

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Imaging of Spinal Cord Tumors

MRI is the investigation of choice for suspected spinal cord tumors.

Lesions may demonstrate abnormal signal intensity, often appearing hyperintense on T2-weighted imaging, depending on tumor type.

MRI also demonstrates the degree of cord or nerve compression.

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Imaging in Bertolotti Syndrome

Radiographs may reveal an enlarged transverse process of the lowest lumbar vertebra contacting or articulating with the sacrum.

The imaging abnormality must correlate with the patient’s symptoms before it is considered the source of pain.

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Imaging in Discitis

Plain radiographs may eventually demonstrate narrowing of the intervertebral disc space, although early studies can be normal.

MRI is more sensitive for early infection and for evaluating adjacent vertebral and soft-tissue involvement.

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Imaging in Pyogenic Sacroiliitis

MRI may demonstrate inflammation, edema, or fluid around the sacroiliac joint.

It is useful for identifying associated abscess formation or surrounding bone involvement.

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Imaging in Scheuermann Disease

The radiographic diagnosis requires anterior wedging of more than 5° in at least three consecutive vertebrae.

Other findings may include irregular endplates and Schmorl nodes.

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Imaging in Disc Herniation

MRI may demonstrate disc bulging, protrusion, extrusion, reduced disc height, or nerve root compression.

It is the preferred imaging modality when neurologic symptoms suggest clinically important disc disease.

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Imaging in Musculoskeletal Pain

Imaging is usually normal in uncomplicated muscular or ligamentous back pain.

When the history and examination are reassuring, normal imaging is not required to establish a clinical diagnosis of musculoskeletal strain.

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Treatment

Treatment depends on identifying the underlying cause.

Management options include activity modification, rest, physical therapy, medication, and surgery.

Most uncomplicated musculoskeletal causes can be treated conservatively.

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Rest and Activity Modification

Rest from the provoking activity is often the first step in treating spondylolysis and low-grade spondylolisthesis.

Repetitive extension, rotation, and impact activities may need to be temporarily avoided.

Activity is gradually resumed after pain improves and strength and flexibility have been restored.

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Physical Therapy

Physical therapy is beneficial for many causes of pediatric back pain.

Treatment may focus on core strengthening, flexibility, hamstring stretching, posture, spinal stabilization, and correction of biomechanical abnormalities.

The program should be tailored to the child’s diagnosis and activity demands.

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Medication

NSAIDs and acetaminophen can be used for symptomatic treatment of many conditions, including musculoskeletal pain, Bertolotti syndrome, and disc herniation.

Medication should be combined with treatment of the underlying cause rather than used as the sole therapy.

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Spondyloarthropathy Treatment

NSAIDs are commonly used as initial treatment for inflammatory spondyloarthropathies.

Patients with persistent active inflammatory disease may require biologic therapy, including tumor necrosis factor inhibitors, under specialist rheumatologic care.

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Osteoid Osteoma Treatment

Pain from osteoid osteoma often responds markedly to NSAIDs.

Definitive treatment may be considered when symptoms persist or medication is undesirable for long-term use.

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Treatment of Discitis

Discitis is generally treated with appropriate antimicrobial therapy when bacterial infection is suspected or confirmed.

Empiric therapy commonly includes coverage against Staphylococcus aureus, with subsequent adjustment according to cultures and clinical response.

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Treatment of Pyogenic Sacroiliitis

Pyogenic sacroiliitis also requires antibiotic therapy directed toward the causative organism.

Staphylococcus aureus is an important pathogen to cover initially when bacterial infection is suspected.

Drainage may be required if an abscess or persistent collection is present.

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Treatment of Neoplasms

Tumors require treatment according to their histologic diagnosis and stage.

Malignant conditions such as Ewing sarcoma may require systemic chemotherapy together with local control by surgery and/or radiotherapy.

Spinal cord tumors require specialist oncologic and neurosurgical evaluation.

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Surgical Management of Spondylolysis

Most cases of spondylolysis are treated nonoperatively.

Persistent symptomatic lesions that fail conservative treatment may occasionally require direct repair of the pars defect using internal fixation and bone grafting.

Fusion may be considered in selected patients with associated instability or advanced spondylolisthesis.

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Surgery for Spondylolisthesis

Progressive or high-grade spondylolisthesis may require spinal fusion, particularly when there is persistent pain, progression of the slip, deformity, or neurologic compromise.

The exact procedure depends on the severity and level of the deformity.

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Surgery for Bertolotti Syndrome

Most patients with Bertolotti syndrome are initially treated conservatively.

Persistent symptoms attributable to the transitional articulation may occasionally require resection or fusion, depending on the anatomical abnormality and pain generator.

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Surgery for Tethered Cord Syndrome

Symptomatic tethered cord syndrome may require surgical detethering.

The goal is to release abnormal attachments and prevent further neurologic deterioration.

Surgery is particularly considered when progressive weakness, sensory loss, deformity, or bladder dysfunction is present.

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Surgery for Disc Herniation

Most pediatric disc herniations are initially managed nonoperatively when neurologic function is preserved.

Persistent radicular pain, progressive neurologic deficit, or significant neural compression may require discectomy, sometimes combined with limited decompression such as laminotomy or laminectomy.

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Follow-Up

Follow-up should be individualized according to the underlying diagnosis.

Children with uncomplicated musculoskeletal pain should demonstrate progressive improvement with activity modification and rehabilitation.

Persistent pain, worsening deformity, new neurologic abnormalities, or constitutional symptoms require reassessment.

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Prognosis

The prognosis is generally favorable for uncomplicated musculoskeletal causes of pediatric back pain.

Many stress-related and mechanical conditions improve with appropriate activity modification and physical therapy.

Prognosis for infection, tumors, neurologic disorders, and structural deformities depends on the underlying condition and how early treatment is initiated.

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Red Flags Requiring Further Evaluation

Features that should prompt more urgent investigation include night pain, persistent or progressive pain, fever, weight loss, fatigue, neurologic deficit, gait disturbance, bowel or bladder dysfunction, and significant spinal tenderness.

Back pain in very young children also deserves a lower threshold for further investigation.

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Patient Monitoring

Children should be monitored for improvement in pain, spinal motion, posture, gait, muscle strength, and neurologic function.

Return to sport should occur gradually after pain has resolved and normal strength, flexibility, and movement have been restored.

Failure to improve as expected should prompt reconsideration of the diagnosis and possible further imaging or specialist referral.

Orthopaedic Surgery - Back Pain

Basics

Low back pain (LBP) is one of the most common musculoskeletal complaints and is a major cause of disability. It accounts for a substantial number of years lived with disability and is responsible for a very large amount of lost work productivity.

An estimated 149 million workdays per year are lost because of low back pain, and approximately 70–80% of adults experience a significant episode of back pain at some point during their lives.

Back pain may involve the bones, joints, ligaments, discs, or muscles of the spine. It occurs most frequently in middle-aged adults but may also affect children and adolescents.

Classification

Back pain can be broadly classified as traumatic or atraumatic.

Pathologic pain may originate directly from the spine, including spondylogenic or neurogenic causes, or may arise from structures outside the spine, including visceral, vascular, or psychogenic sources.

Because low back pain is a symptom rather than a single disease, careful clinical assessment is necessary to determine its underlying cause.

Synonyms

Common terms include backache and low back pain (LBP).

Epidemiology

Low back pain is extremely common in adults.

It is less common in children, and significant back pain in a child should prompt careful investigation.

Children or adolescents with scoliosis may report mild discomfort, but severe or persistent pain should raise concern for conditions such as infection, tumor, fracture, or another structural abnormality.

Age Considerations

The prevalence of chronic low back pain increases with age and is highest during approximately the fifth and sixth decades of life.

Most surgical procedures performed for low back pain occur in patients between approximately 35 and 55 years of age.

Sex Distribution

Back pain has historically been reported more frequently in males, partly because of greater exposure to manual labor, motor vehicle trauma, and industrial accidents.

However, low back pain affects both sexes and is common across the general population.

Incidence

Approximately 25% of adults in the United States report experiencing low back pain over a given period.

The burden of disease is substantial because symptoms may interfere with work, exercise, mobility, sleep, and activities of daily living.

Prevalence

The point prevalence of chronic low back pain among adults aged approximately 20–69 years has been reported at around 13%.

The likelihood of chronic symptoms rises with age.

Risk Factors

Important risk factors include obesity, cigarette smoking, manual labor, and traumatic accidents.

Repeated heavy lifting, prolonged mechanical loading, poor physical conditioning, and certain occupational exposures may also contribute.

Genetics

There is no single established genetic predisposition that explains most cases of nonspecific low back pain.

However, inherited factors may contribute indirectly to certain disorders, such as degenerative disc disease or inflammatory spondyloarthritis.

Pathophysiology

There is no single pathologic process responsible for all forms of back pain.

The mechanism depends on the underlying disorder and may involve mechanical strain, disc degeneration, nerve compression, inflammation, fracture, infection, neoplasm, or referred pain from other structures.

Etiology

Traumatic Causes

Traumatic causes include vertebral fractures or microfractures, fracture-dislocations, intervertebral disc herniation, and ligamentous injuries.

Fractures and major structural injuries usually produce sudden and often severe pain following trauma.

Atraumatic Causes

Atraumatic causes include degenerative disc disease, degenerative spinal stenosis, inflammatory arthritis, osteoporosis, spondylolysis, spondylolisthesis, infection, and neoplasms.

Tumors may be primary bone lesions or metastatic disease.

Associated Conditions

Low back pain may occur in association with ankylosing spondylitis, rheumatoid arthritis, sciatica, and cauda equina syndrome.

Neurologic symptoms accompanying back pain require particular attention because they may indicate nerve root or spinal canal compromise.

Diagnosis

Signs and Symptoms

Common symptoms include low back pain, stiffness, and numbness.

Patients may also experience radiating pain into the buttocks or lower extremities when nerve roots are involved.

Neurologic Signs

Potential examination findings include paravertebral muscle spasm, motor weakness, loss of deep tendon reflexes, sensory loss, clonus, and a positive Babinski sign.

The presence of upper motor neuron findings or significant neurologic deficits should prompt further investigation.

History

A detailed history is essential because routine diagnostic studies are often unnecessary in uncomplicated low back pain.

The clinician should determine the onset, location, severity, duration, and character of pain, together with aggravating and relieving factors.

A history of trauma, systemic illness, malignancy, infection risk, osteoporosis, or neurologic symptoms is particularly important.

Pain Mapping

Rather than relying only on verbal descriptions, asking the patient to identify or map the exact distribution of pain can improve localization.

The pattern may help distinguish localized mechanical pain from radicular, referred, or systemic causes.

Red Flag History

Important concerning features include night pain, unexplained weight loss, fever, recent serious trauma, history of malignancy, immunosuppression, intravenous drug use, progressive neurologic deficit, or bowel and bladder dysfunction.

These findings may indicate serious structural disease and require urgent investigation.

Physical Examination

Examination begins with inspection of the spine and overall posture.

The clinician should assess for asymmetry of the ribs, flanks, pelvis, or shoulders, and should observe the normal sagittal spinal curves.

Deformities such as scoliosis, excessive kyphosis, or abnormal lumbar lordosis should be documented.

Range of Motion

Lumbar motion should be assessed in flexion, extension, lateral bending, and rotation.

Pain suddenly reproduced during a specific movement may suggest a mechanical abnormality.

Restriction of motion may occur because of pain, muscle spasm, degenerative disease, inflammation, or structural deformity.

Palpation

The lumbar spine and surrounding muscles should be palpated for tenderness.

Paravertebral muscle spasm may be present in acute mechanical pain.

Percussion tenderness over the spine may raise concern for fracture, infection, or other osseous pathology.

Neurologic Examination

The neurologic examination is a crucial component of assessment.

It should include motor strength, sensory testing, deep tendon reflexes, and gait evaluation.

The distribution of weakness or sensory loss may help identify the involved nerve root.

Motor Testing

Major muscle groups of the lower extremities should be examined systematically.

Weakness may indicate nerve root compression, spinal cord involvement, severe pain inhibition, or another neurologic disorder.

Reflexes

Deep tendon reflexes should be assessed and compared bilaterally.

Abnormal or absent reflexes may indicate nerve root involvement, whereas hyperreflexia, clonus, or a positive Babinski response may suggest spinal cord pathology.

Gait Examination

The patient’s gait should be observed for antalgia, weakness, foot drop, imbalance, or other neurologic abnormalities.

Difficulty with heel or toe walking may provide additional information regarding specific nerve root or muscle dysfunction.

Laboratory Tests

There are no routine laboratory tests required for uncomplicated mechanical low back pain.

Investigations should be guided by clinical suspicion.

Evaluation for Infection

When infection is suspected, a complete blood count and erythrocyte sedimentation rate (ESR) may be obtained.

Inflammatory markers are commonly elevated in spinal infection, with ESR often being particularly useful.

C-reactive protein may also assist in assessing inflammatory activity.

Evaluation for Multiple Myeloma

In older patients, particularly those over approximately 50 years of age with unexplained persistent back pain, laboratory investigations may be used to screen for disorders such as multiple myeloma when clinically indicated.

HLA-B27 Testing

In younger patients with marked spinal stiffness and symptoms suggestive of inflammatory back pain, testing for HLA-B27 may support evaluation for ankylosing spondylitis.

It should not be used as a stand-alone diagnostic test.

Imaging

Plain Radiographs

Routine radiographs are not necessary for every first episode of uncomplicated low back pain, particularly when symptoms follow a minor mechanical event such as lifting and there are no concerning findings.

Imaging should be considered when history or examination suggests a significant structural abnormality.

Indications for Imaging

Radiographs may be appropriate when there is suspicion of fracture, ankylosing spondylitis, severe deformity, malignancy, infection, or another important structural disorder.

The decision to image should be based on clinical findings rather than pain alone.

CT

Computed tomography is particularly useful for evaluating bony abnormalities.

It can provide detailed assessment of fractures, pars defects, osteoid osteoma, and other osseous lesions.

CT is also helpful when complex anatomy must be defined before surgery.

MRI

MRI provides excellent visualization of bone marrow, discs, ligaments, neural structures, and surrounding soft tissues.

It is particularly useful for detecting disc herniation, spinal stenosis, infection, metastatic disease, marrow abnormalities, and nerve compression.

MRI is generally the preferred advanced imaging modality when neurologic symptoms or serious spinal pathology are suspected.

Bone Scintigraphy

Technetium bone scanning can help detect areas of increased skeletal activity.

It may be useful for identifying early bone infection, stress injury, occult fracture, or metastatic lesions.

Its use has decreased in many situations because MRI often provides more detailed anatomic information.

Differential Diagnosis in Adults

Traumatic Causes

Important traumatic causes include herniated disc, compression fracture, fracture-dislocation, and traumatic spondylolysis.

A clear traumatic history increases suspicion for these conditions.

Atraumatic Causes in Adults

Atraumatic causes include degenerative disc disease, spinal stenosis, inflammatory arthritis, spondylolysis, spondylolisthesis, ligamentous or muscular strain, and neoplasm.

Malignant causes include metastatic bone disease and multiple myeloma.

Differential Diagnosis in Children

Back pain in children deserves careful attention because serious causes are relatively more important.

Traumatic causes include fracture and disc herniation.

Atraumatic causes include scoliosis, disc-space infection, vertebral osteomyelitis, and tumors.

Persistent severe pain should not automatically be attributed to muscular strain.

Treatment

General Measures

Most patients with uncomplicated low back pain can be managed nonoperatively.

Treatment may include short-term rest, appropriate analgesia, NSAIDs when indicated, activity modification, and physical therapy.

The overall aim is to restore mobility and prevent deconditioning.

Bed Rest

Prolonged bed rest is generally not beneficial.

In patients with severe acute spasm or pain, a very short period of rest—often no more than 2–3 days—may be reasonable.

During the first several days, activity may be temporarily restricted, but progressive mobilization should begin as symptoms improve.

Early Mobilization

If no serious structural abnormality is identified, patients should gradually resume activity.

Early mobilization helps prevent muscle weakness, stiffness, loss of cardiovascular fitness, and prolonged disability.

Physical Therapy

Physical therapy and structured exercise can improve back strength, flexibility, range of motion, posture, and general fitness.

Therapy should be tailored to the underlying diagnosis and the patient’s functional limitations.

Exercise Programs

Traditional exercise approaches include the Williams flexion program and McKenzie extension-based exercises.

No single exercise method is appropriate for every patient.

Programs emphasizing coordination, stabilization, strength, and resistance training are particularly useful in chronic low back pain.

Core and Stabilization Training

Exercises targeting the abdominal, paraspinal, pelvic, and hip muscles can improve spinal stability.

Motor-control and stabilization programs may reduce recurrent symptoms and improve function in patients with chronic mechanical low back pain.

Activity Modification

Patients should be educated regarding safe lifting techniques, posture, gradual return to activity, and strategies for preventing recurrent injury.

Temporary modification of work or sporting activity may be required during painful episodes.

Work-Hardening Programs

Patients injured at work may benefit from a structured work-hardening program.

These programs progressively reproduce occupational tasks in a controlled setting and help restore strength, endurance, and confidence before return to full duty.

Passive Therapies

Massage, acupuncture, electrical stimulation, and other passive modalities may provide temporary symptom relief.

However, they generally provide less durable benefit than active exercise and strengthening programs.

They should therefore be considered adjuncts rather than the primary long-term treatment.

Medication

NSAIDs

Nonsteroidal anti-inflammatory drugs are commonly used for short-term symptomatic relief.

They may reduce pain and inflammation sufficiently to allow earlier mobilization and participation in rehabilitation.

Treatment should be individualized according to gastrointestinal, renal, cardiovascular, and other patient-specific risks.

Duration of Medication

NSAIDs may be prescribed for several weeks when necessary, but treatment should be reassessed regularly.

Once symptoms improve, medication can usually be reduced or discontinued.

Muscle Relaxants

Muscle relaxants have a limited role in routine management.

They may be useful for short-term relief in patients with severe muscle spasm, especially during an acute episode.

They are generally not recommended for prolonged use.

Treatment of Spinal Infection

When infection is present, treatment requires appropriate antimicrobial therapy and management of the infected spinal segment.

Intravenous antibiotics are commonly required initially.

Inflammatory markers such as ESR and CRP may be followed to assess response to treatment.

Surgical Management

Only a minority of patients with low back pain require surgery.

Approximately 1–5% may ultimately become candidates for operative treatment, depending on the underlying pathology.

Surgery is generally reserved for clearly defined structural problems that fail to respond to appropriate conservative care or threaten neurologic function.

Surgical Principles

The principal surgical goals include decompression of compressed nerve roots or the spinal cord, stabilization of an unstable spine, and correction of significant deformity.

The exact procedure depends on the diagnosis.

Decompression

Nerve root or spinal cord compression may require surgical decompression.

Examples include significant disc herniation, spinal stenosis, tumor, infection, or traumatic compression associated with neurologic deficits.

Spinal Fusion

Fusion may be used when instability is present or when decompression would otherwise leave the spine unstable.

It can also be considered for selected cases of deformity, spondylolisthesis, or severe degenerative disease.

Fusion solely for nonspecific low back pain is relatively uncommon.

Deformity Correction

Patients with significant spinal deformities such as scoliosis or spondylolisthesis may require realignment combined with fusion.

Correction is generally considered when deformity is progressive, symptomatic, unstable, or neurologically compromising.

Instrumentation

Modern spinal fusion may use a variety of fixation systems.

Examples include pedicle screws, rods, plates, and interbody devices.

Instrumentation provides mechanical stability and increases the likelihood of obtaining a solid fusion.

Lumbar Disc Arthroplasty

Lumbar disc replacement has been developed as an alternative to fusion for selected patients with persistent discogenic low back pain.

The objective is to remove the painful disc while preserving motion at the involved spinal level.

Short-term outcomes have been encouraging in appropriately selected patients.

Limitations of Disc Arthroplasty

Longer-term studies have demonstrated that prosthetic disc motion may gradually decrease over time.

Because of concerns regarding durability, patient selection, adjacent-segment effects, and revision surgery, lumbar disc arthroplasty remains controversial in some settings.

Follow-Up

Patients with uncomplicated low back pain should be reviewed according to symptom severity and functional limitation.

Follow-up at approximately 4–6-week intervals may be appropriate until substantial improvement occurs.

Persistent or worsening symptoms should prompt reconsideration of the diagnosis.

Prognosis

The prognosis is generally good in patients without major structural abnormalities.

Many episodes improve with activity modification, appropriate medication, exercise, and rehabilitation.

However, recurrent or chronic symptoms are common in some patients.

Prognosis After Fusion

Patients who undergo major spinal fusion can often return to many routine activities.

However, heavy manual work and repeated high-load activities may remain difficult because spinal motion is reduced and adjacent segments experience greater mechanical demand.

Complications

Potential complications of spinal disease and its treatment include infection, neurologic injury, surgical failure, pseudarthrosis, loss of fixation, and persistent unexplained pain.

Complication risk varies according to the underlying disorder and surgical procedure.

Pseudarthrosis

Pseudarthrosis refers to failure of a planned spinal fusion to unite.

It may result in persistent pain, hardware failure, deformity, or instability and may occasionally require revision surgery.

Cauda Equina Syndrome

Cauda equina syndrome is a neurologic emergency caused by severe compression of the cauda equina nerve roots.

It may result from a large disc herniation, tumor, infection, fracture, or other space-occupying lesion.

Signs of Cauda Equina Syndrome

Concerning findings include progressive bilateral leg weakness, saddle anesthesia, urinary retention or incontinence, bowel dysfunction, and severe neurologic loss.

Untreated compression can result in permanent paralysis and irreversible loss of bladder and bowel function.

Urgent imaging and surgical evaluation are required.

Patient Monitoring

Patients should demonstrate gradual improvement with rest, activity modification, appropriate medication, and rehabilitation.

Range of motion, strength, gait, neurologic function, and ability to perform daily activities should be monitored.

If pain fails to improve as expected or new neurologic or systemic symptoms develop, a significant structural or systemic cause should be reconsidered.

Orthopaedic Surgery - Atypical Stress Fractures

Basics

Atypical stress fractures most commonly involve the subtrochanteric region or femoral shaft and are strongly associated with prolonged bisphosphonate therapy.

These fractures occur distal to the lesser trochanter and proximal to the supracondylar region of the femur.

They generally result from a low-energy mechanism, such as a fall from standing height, and some patients report no preceding traumatic event at all.

A characteristic radiographic feature is localized thickening or beaking of the lateral femoral cortex.

The fracture is usually transverse or short oblique, is generally noncomminuted, and may occasionally demonstrate a medial cortical spike.

Epidemiology

The reported incidence of atypical femoral fractures is approximately 50–130 cases per 100,000 patient-years.

The true incidence may be lower because epidemiologic studies sometimes have difficulty consistently identifying fractures that meet formal atypical femoral fracture criteria.

These fractures remain substantially less common than typical osteoporotic hip fractures.

They appear to occur more frequently in women and individuals of Asian ethnicity.

Risk Factors

The most important risk factor is long-term bisphosphonate use.

The risk increases with longer duration of treatment and becomes more significant after approximately 4 years of continuous therapy, although atypical fractures have been reported after as little as 1.5 years of treatment.

Other recognized risk factors include Asian ethnicity, prolonged glucocorticoid therapy, autoimmune disease, obesity with a BMI greater than 30 kg/m², age younger than approximately 70 years, and earlier menopause.

Etiology and Pathophysiology

The principal proposed mechanism is prolonged suppression of normal bone remodeling caused by bisphosphonates.

The femur is exposed to repetitive mechanical loading during everyday activities. This produces microscopic damage, particularly along the lateral cortex, which normally undergoes continuous remodeling and repair.

Bisphosphonate therapy can markedly reduce bone turnover. When remodeling is excessively suppressed, microdamage may accumulate rather than being repaired.

Over time, small cortical cracks may propagate and eventually develop into an incomplete or complete atypical fracture.

Mechanical Factors

The lateral femoral cortex experiences considerable tensile stress during weight-bearing.

Certain anatomical characteristics can increase these stresses, including lateral femoral bowing and varus alignment of the proximal femur.

These mechanical factors may concentrate forces along the lateral cortex and increase susceptibility to fracture.

Genetic Factors

A genetic predisposition has also been reported in some patients.

The precise genetic contribution remains incompletely understood, but inherited differences in bone remodeling or femoral geometry may influence susceptibility.

Associated Conditions

Atypical femoral fractures are frequently encountered in patients with osteoporosis receiving prolonged bisphosphonate treatment.

They may also occur in individuals with autoimmune disorders who have required prolonged glucocorticoid therapy, which can adversely affect bone quality and healing.

Diagnosis

Signs and Symptoms

Some patients are completely asymptomatic before sustaining a complete fracture.

Others experience characteristic prodromal pain for weeks or months before the fracture becomes complete.

The pain is often described as a dull or aching discomfort involving the groin or thigh, particularly during weight-bearing.

Symptoms may be vague or sharply localized.

History

The clinical history should specifically assess the duration of bisphosphonate use.

Although the greatest concern traditionally involves treatment extending beyond 4–5 years, atypical fractures can occur earlier.

A history of long-term glucocorticoid use should also be documented.

Patients should be questioned about preceding thigh or groin pain and whether symptoms worsen with walking or prolonged standing.

Physical Examination

Patients with an incomplete fracture may have localized tenderness along the thigh and pain during weight-bearing.

Hip range of motion may reproduce discomfort, particularly internal rotation.

A complete displaced fracture usually results in inability to bear weight.

Visible deformity and shortening of the affected limb may also be present.

Imaging

Plain Radiographs

Initial evaluation should include an anteroposterior radiograph of the pelvis together with AP and lateral views of the hip, entire femur, and knee.

It is important to image the entire femur because the lesion may occur anywhere from the subtrochanteric region to the distal shaft.

Early Radiographic Findings

Before a complete fracture develops, radiographs may show focal periosteal reaction, cortical thickening, or beaking along the lateral femoral cortex.

These changes may represent an impending atypical fracture.

A transverse radiolucent line extending inward from the lateral cortex may indicate an incomplete fracture.

Complete Fracture Pattern

Complete atypical femoral fractures are typically transverse or short oblique.

The fracture pattern is usually simple and demonstrates little or no comminution.

A characteristic medial cortical spike may occasionally be present.

These features help distinguish atypical fractures from typical high-energy femoral shaft fractures.

Contralateral Femur Imaging

Atypical femoral fractures are frequently bilateral or sequential.

Therefore, radiographs of the contralateral femur should routinely be obtained when an atypical fracture is identified.

The opposite femur should be examined for cortical thickening, beaking, periosteal reaction, or a transverse radiolucent line.

MRI

MRI is generally unnecessary when a complete fracture is clearly visible on radiographs.

However, it is the preferred imaging study for detecting an occult or incomplete atypical fracture when plain radiographs are normal or equivocal but clinical suspicion remains high.

Typical findings include bone marrow edema and a linear low-signal fracture line.

MRI is particularly useful in patients receiving long-term bisphosphonates who present with unexplained thigh or groin pain.

Bone Scintigraphy

Bone scintigraphy may detect increased metabolic activity at an impending fracture site.

However, it is less specific than MRI and is not generally required when a complete fracture is already visible radiographically.

It may be useful when MRI cannot be performed.

CT

CT is also usually unnecessary for complete atypical fractures.

It has lower sensitivity than MRI for detecting early stress reactions and incomplete fractures.

Its use is therefore generally reserved for selected cases in which detailed cortical anatomy is required.

Dual-Energy X-Ray Absorptiometry

Dual-energy X-ray absorptiometry may occasionally identify cortical abnormalities such as periosteal reaction or lateral cortical beaking during monitoring of patients receiving prolonged bisphosphonate therapy.

Its primary purpose remains assessment of bone mineral density rather than diagnosis of atypical fracture.

Differential Diagnosis

The differential diagnosis includes insufficiency fracture, intertrochanteric or peritrochanteric fracture, typical osteoporotic hip fracture, and femoral neck stress fracture.

Musculoskeletal conditions such as overuse tendinopathy may also produce thigh or groin pain and can mimic prodromal symptoms.

Treatment

General Measures

Long-term bisphosphonate therapy should be reassessed in patients at increased risk of atypical femoral fracture.

A drug holiday may be considered in appropriate patients after balancing the risk of atypical fracture against the continuing risk of osteoporotic fragility fracture.

Patients receiving bisphosphonates for approximately 3–5 years or longer should be monitored for symptoms suggestive of an atypical femoral fracture.

Monitoring for Prodromal Symptoms

Patients on prolonged bisphosphonate treatment should be questioned about new groin or thigh pain, particularly pain occurring during weight-bearing.

When such symptoms develop, imaging should be obtained promptly.

Early identification of an incomplete lesion may allow prophylactic treatment before displacement occurs.

Laboratory Evaluation

Bone turnover markers may occasionally be assessed when excessive suppression of remodeling is suspected.

Potential investigations include serum or urine N-telopeptide or C-telopeptide levels and bone-specific alkaline phosphatase.

These tests may provide information about bone turnover but do not establish the diagnosis of an atypical fracture.

Weight-Bearing Restrictions

Patients with prodromal pain and radiographic or imaging evidence of an incomplete fracture should reduce loading of the affected limb.

Partial or non-weight-bearing may be recommended while definitive treatment is arranged.

The objective is to reduce the risk of progression to a complete displaced fracture.

Surgical Management

Intramedullary Nailing

Intramedullary nailing is the preferred treatment for most complete atypical femoral fractures.

It is also commonly recommended for incomplete fractures that are painful or demonstrate features indicating a high risk of progression.

The intramedullary device provides load-sharing fixation along the length of the femur and allows early mobilization.

Incomplete Fractures

Incomplete atypical fractures have a substantial risk of progressing to complete displaced fractures.

This risk is particularly high when a visible radiolucent fracture line, lateral cortical beaking, and persistent prodromal pain are present.

Observation alone may therefore be inappropriate in high-risk lesions.

Prophylactic Intramedullary Nailing

Prophylactic intramedullary fixation may be recommended for patients with an incomplete atypical lesion before a displaced fracture occurs.

Important indications include lateral cortical beaking combined with persistent thigh or groin pain.

Preventive fixation can reduce the likelihood of sudden complete fracture and may allow a more predictable recovery.

Plate Fixation

Intramedullary nailing may be technically difficult in patients with substantial femoral bowing.

In such situations, lateral plate fixation may be considered.

The choice of fixation should take femoral geometry, fracture location, and surgeon experience into account.

Contralateral Femur Management

Management of the opposite femur is controversial.

Routine prophylactic fixation of an asymptomatic contralateral femur is not recommended for every patient.

However, prophylactic intramedullary nailing may be considered when multiple high-risk features are present.

High-Risk Contralateral Features

Factors that may support prophylactic fixation of the opposite femur include Asian ethnicity, prodromal thigh pain, varus proximal femoral geometry, marked femoral bowing, and radiographic abnormalities such as cortical beaking or a transverse radiolucent line.

The decision should be individualized according to overall fracture risk and symptoms.

Follow-Up

Patients require close follow-up after both operative and nonoperative management.

Serial radiographs are used to assess healing, implant position, and possible progression of incomplete lesions.

The contralateral femur should also be monitored because a second atypical fracture may develop later.

Prognosis

Intramedullary fixation generally permits relatively early or immediate protected weight-bearing and facilitates return to function.

However, atypical femoral fractures often heal more slowly than typical traumatic femoral fractures.

They have a higher incidence of delayed union, nonunion, and revision surgery compared with more typical hip or femoral fractures.

Delayed Healing

Suppressed bone remodeling and the chronic stress-fracture nature of the injury may contribute to prolonged healing.

Radiographic union can therefore take considerable time even after technically successful fixation.

Patients should be counseled that recovery may be slower than after a conventional femoral fracture.

Complications

An incomplete atypical fracture may progress to a complete displaced fracture, particularly if weight-bearing continues despite prodromal symptoms.

Other important complications include delayed union, nonunion, implant-related problems, and the development of an atypical fracture in the contralateral femur.

Contralateral Fracture

Patients who sustain one atypical femoral fracture have an increased risk of developing a similar lesion on the opposite side.

Persistent or new contralateral thigh pain should therefore be investigated promptly.

Long-term surveillance of both femora may be appropriate in high-risk individuals.

Patient Teaching

Patients receiving long-term bisphosphonate therapy should understand that atypical femoral fractures are uncommon but recognized complications of prolonged treatment.

They should be advised to report new groin or thigh pain during weight-bearing, even if there has been no trauma.

Early Warning Signs

Patients should understand that an atypical fracture may initially produce no symptoms.

When symptoms do occur, vague aching pain in the thigh or groin may precede complete fracture by weeks or months.

Radiographs may show lateral cortical thickening or beaking before the fracture becomes complete.

Importance of Early Evaluation

Early recognition of an impending atypical femoral fracture can prevent progression to a displaced injury.

Patients with significant prodromal symptoms, radiographic abnormalities, or other high-risk findings should undergo prompt orthopedic evaluation.

Patients with a complete atypical fracture, or those with an incomplete lesion at high risk of progression, commonly require surgical stabilization.

Orthopaedic Surgery - Arthroscopy

Basics

Arthroscopy is a minimally invasive surgical technique that allows direct visualization and treatment of structures within a joint through small portal incisions.

The procedure should be performed only after a complete clinical history, thorough physical examination, and appropriate imaging studies have been obtained.

Most arthroscopic procedures can be performed on an outpatient basis, although the postoperative course depends on the joint involved and the complexity of the procedure.

General Principles

Arthroscopy uses a small camera, or arthroscope, inserted through one portal while surgical instruments are introduced through one or more additional portals.

The technique allows the surgeon to inspect articular cartilage, ligaments, tendons, menisci, labral structures, synovium, and other intra-articular tissues.

In addition to diagnostic evaluation, many abnormalities can be treated during the same procedure.

Knee Arthroscopy

Indications

Common indications for knee arthroscopy include meniscal repair or debridement, treatment of meniscal cysts, management of osteochondral lesions, and reconstruction or debridement of anterior or posterior cruciate ligament injuries.

It may also be performed for synovial biopsy, synovectomy, evaluation of unexplained knee pain or instability, and selected cases of degenerative joint disease requiring debridement.

Procedure

Knee arthroscopy is usually performed through two or more small portal incisions, each measuring approximately 0.5 cm.

One portal is used for the arthroscope, while the remaining portals permit insertion of surgical instruments.

The technique allows systematic visualization of all three major compartments of the knee: the patellofemoral, medial, and lateral compartments.

Articular Cartilage Assessment

The articular cartilage of the femur, tibia, and patella can be directly inspected.

The surgeon can evaluate cartilage for degeneration, fissuring, osteochondral defects, loose fragments, or traumatic injury.

Selected cartilage lesions may be treated arthroscopically during the same procedure.

Meniscal Assessment

Both the medial and lateral menisci can be visualized and probed.

Probing helps determine the location, configuration, stability, and extent of a meniscal tear.

Depending on the tear pattern and vascularity, treatment may involve meniscal repair or selective debridement.

Cruciate Ligament Assessment

The anterior cruciate ligament and posterior cruciate ligament can also be visualized and probed arthroscopically.

Their integrity, tension, attachment sites, and associated injuries can be assessed.

ACL and PCL reconstruction can be performed with arthroscopic assistance.

Postoperative Weight-Bearing

After uncomplicated knee arthroscopy, many patients can begin partial or full weight-bearing with crutch assistance soon after surgery.

The exact amount of permitted weight-bearing depends on the procedure performed.

For example, rehabilitation after simple debridement may progress more rapidly than after meniscal repair, cartilage restoration, or ligament reconstruction.

Rehabilitation After Knee Arthroscopy

The duration of rehabilitation varies according to the underlying injury and surgical procedure.

Physical therapy commonly focuses on restoring range of motion, gait, core stability, quadriceps strength, and hamstring strength.

The rehabilitation protocol should be individualized rather than based solely on the fact that arthroscopy was performed.

Shoulder Arthroscopy

Indications

Shoulder arthroscopy may be performed for a wide variety of conditions.

Common indications include shoulder instability, synovial or tissue biopsy, removal of loose bodies, subacromial impingement, rotator cuff tears, and superior labral anterior-posterior (SLAP) lesions.

It can provide both diagnostic assessment and definitive surgical treatment.

Procedure

Shoulder arthroscopy typically requires two or more portals, generally measuring approximately 0.8 cm.

The arthroscope is introduced into the glenohumeral joint to inspect the articular surfaces and surrounding soft tissues.

Additional portals provide access for probing, debridement, repair, and fixation.

Articular Cartilage Assessment

The articular surfaces of the glenoid and humeral head can be inspected directly.

Arthroscopy may identify abnormalities such as osteoarthritis, cartilage defects, osteochondral fragments, or loose bodies.

The severity and distribution of cartilage damage can therefore be assessed accurately.

Glenohumeral Ligament Assessment

The major soft-tissue stabilizers of the shoulder can be examined arthroscopically.

These include the inferior, middle, and superior glenohumeral ligament complexes.

Their integrity is particularly important when evaluating recurrent instability or previous dislocation.

Labral Assessment

The glenoid labrum can be inspected throughout its circumference.

Arthroscopy can identify Bankart lesions, SLAP tears, degenerative labral changes, and other labral injuries.

The stability of the labrum can also be assessed with a probe.

Subacromial Assessment

When rotator cuff or impingement symptoms are present, arthroscopy can be extended into the subacromial space.

The rotator cuff, bursa, undersurface of the acromion, and surrounding structures are examined for causes of mechanical impingement or tendon injury.

Arthroscopic Stabilization

Recurrent shoulder instability can often be treated arthroscopically.

Procedures may include Bankart repair or capsulolabral stabilization, in which the detached labrum and capsule are restored to the glenoid rim.

These procedures aim to restore stability while preserving shoulder motion.

Acromioplasty

Arthroscopic acromioplasty may be performed in selected cases of mechanical subacromial impingement.

The procedure involves reshaping part of the acromion and removing impinging tissue to increase the available space for the rotator cuff.

Rotator Cuff Repair

Many rotator cuff tears can be repaired arthroscopically.

The torn tendon is mobilized and reattached to its insertion on the greater tuberosity, commonly using suture anchors.

Arthroscopic repair allows treatment through small portals while minimizing disruption of the surrounding deltoid muscle.

SLAP Lesions

SLAP lesions may be treated with arthroscopic repair or debridement, depending on the tear pattern, patient age, activity level, and associated pathology.

Direct visualization allows accurate evaluation of the superior labrum and biceps anchor.

Rehabilitation After Shoulder Arthroscopy

Physical therapy is an essential component of recovery after shoulder arthroscopy.

Early rehabilitation usually emphasizes restoring appropriate motion while protecting repaired tissues.

Later stages focus on strengthening the rotator cuff, scapular stabilizers, and other dynamic stabilizers of the shoulder.

The duration and progression of rehabilitation depend on the operation performed.

Hip Arthroscopy

Indications

Hip arthroscopy may be used for synovial biopsy, synovectomy, removal of loose bodies, and treatment of labral tears.

Because the hip is a deep, constrained joint, specialized traction and instrumentation are generally required.

Labral Treatment

Hip arthroscopy allows direct inspection of the acetabular labrum.

Symptomatic labral tears may be treated with repair, selective debridement, or other arthroscopic techniques, depending on the pattern and quality of the tissue.

Loose-Body Removal

Intra-articular loose bodies can produce pain, locking, catching, and restricted motion.

Arthroscopy permits their removal without requiring a large open surgical exposure.

Ankle Arthroscopy

Indications

Ankle arthroscopy may be performed for synovial biopsy or synovectomy, removal of loose bodies, excision of bone spurs, and treatment of osteochondral lesions.

It is particularly useful for disorders causing mechanical impingement, locking, or persistent intra-articular pain.

Osteochondral Lesions

Osteochondral lesions of the talus can be evaluated directly during ankle arthroscopy.

Depending on the size and characteristics of the lesion, treatment may include debridement, stabilization of unstable cartilage, or marrow-stimulation techniques.

Bone-Spur Removal

Anterior or posterior ankle osteophytes can produce painful impingement during motion.

Arthroscopic excision of selected osteophytes can improve movement and relieve mechanical symptoms.

Elbow Arthroscopy

Indications

Elbow arthroscopy may be used for synovial biopsy, synovectomy, loose-body removal, and debridement of cartilage lesions or osteophytes.

It can be especially useful in patients with mechanical locking, restricted motion, or symptomatic intra-articular pathology.

Cartilage and Osteophyte Debridement

Degenerative cartilage fragments and osteophytes may restrict elbow motion and cause pain.

Arthroscopic debridement can remove these structures while minimizing soft-tissue disruption compared with some open procedures.

Wrist Arthroscopy

Indications

Wrist arthroscopy may be performed for synovial biopsy, synovectomy, removal of loose bodies, and diagnosis or treatment of triangular fibrocartilage complex (TFCC) injuries.

It provides detailed visualization of small intra-articular structures that may be difficult to assess using imaging alone.

TFCC Assessment

The triangular fibrocartilage complex can be directly inspected and probed arthroscopically.

Tears may be assessed according to their location, stability, and tissue quality.

Depending on the lesion, treatment may involve debridement or repair.

Advantages of Arthroscopy

Arthroscopy generally requires smaller incisions than traditional open surgery.

Potential benefits include less disruption of surrounding soft tissues, improved visualization of intra-articular structures, and the ability to diagnose and treat several abnormalities during the same procedure.

Many procedures can also be performed without overnight hospitalization.

Limitations

Arthroscopy is not appropriate for every joint disorder.

The decision to operate should be based on the patient’s symptoms, physical examination, imaging, functional impairment, and likelihood that the identified pathology is responsible for the symptoms.

Abnormal imaging alone does not necessarily justify arthroscopic surgery.

Postoperative Rehabilitation

Rehabilitation should always be tailored to the specific procedure performed.

Simple diagnostic arthroscopy or debridement may allow rapid progression of activity.

Procedures involving meniscal repair, ligament reconstruction, labral repair, rotator cuff repair, or cartilage treatment generally require more prolonged protection and structured rehabilitation.

Patient Monitoring

Postoperative follow-up should assess wound healing, pain, swelling, joint range of motion, strength, and functional recovery.

Patients should also be monitored for complications such as infection, stiffness, neurovascular symptoms, or persistent mechanical complaints.

Progression of weight-bearing, strengthening, and return to sport should follow the requirements of the specific arthroscopic procedure rather than a single universal protocol.

Orthopaedic Surgery - Arthrocentesis

Basics

Arthrocentesis is a procedure in which synovial fluid is aspirated from a joint using a needle.

It may be performed for either diagnostic or therapeutic purposes.

Diagnostic aspiration allows examination of synovial fluid for infection, crystals, blood, and inflammatory changes, while therapeutic aspiration can reduce pressure, pain, and restricted movement caused by a large joint effusion.

Causes of Joint Effusion

A joint effusion may develop from many different conditions.

Important causes include infection, crystal arthropathies, hemophilia, autoimmune inflammatory disorders, trauma, and pigmented villonodular synovitis (PVNS).

The appearance and composition of the aspirated fluid can provide valuable information regarding the underlying diagnosis.

Indications

Synovial joints may be aspirated for several reasons.

One of the most important indications is to exclude septic arthritis, particularly when a joint is acutely painful, swollen, and warm.

Arthrocentesis is also useful for diagnosing gout, pseudogout, inflammatory arthritis, hemarthrosis, and other arthropathies.

Therapeutically, aspiration can reduce pain and improve movement by decreasing pressure within a tense joint effusion.

Signs and Symptoms

A joint containing sufficient fluid for aspiration usually has a clinically detectable effusion.

Patients may complain of pain, swelling, stiffness, and difficulty moving the affected joint.

Infectious, inflammatory, and crystalline arthropathies commonly produce a joint that is warm and tender.

Erythema may be present over the joint, although surrounding cellulitis must be distinguished carefully because it affects the safe approach for aspiration.

Physical Examination

The affected joint should be inspected and palpated for swelling, warmth, tenderness, erythema, and the presence of an effusion.

Range of motion should be assessed when tolerated.

Patients with septic arthritis, crystal arthropathy, or acute traumatic injury may have substantial restriction of both active and passive movement.

The surrounding skin should also be examined for abrasions, wounds, cellulitis, bruising, or other evidence of trauma or infection.

Common Sites for Joint Aspiration

The optimal needle entry site depends on the joint involved.

The elbow is commonly approached posterolaterally.

The shoulder can be aspirated anteriorly, although ultrasound, CT, or fluoroscopic guidance may improve accuracy.

The hip can be approached anteriorly or laterally and generally benefits from imaging guidance because of its depth and proximity to major neurovascular structures.

The knee is commonly aspirated from either the medial or lateral side through the suprapatellar pouch.

The ankle is often approached from the anterolateral aspect.

Synovial Fluid Assessment

Synovial fluid should be assessed according to its appearance, white blood cell count, proportion of polymorphonuclear leukocytes, crystal content, Gram stain, and culture.

Additional biochemical or molecular testing may be performed depending on the suspected diagnosis.

The overall pattern is interpreted together with the clinical presentation rather than relying on a single laboratory value.

Noninflammatory Synovial Fluid

Noninflammatory fluid is generally clear or straw-colored.

The white blood cell count is usually relatively low, and the proportion of polymorphonuclear cells is limited.

This type of fluid may be seen in conditions dominated by degenerative rather than active inflammatory changes.

Inflammatory Synovial Fluid

Inflammatory fluid is commonly cloudy or yellow and contains an increased number of white blood cells.

Inflammatory arthropathies, including rheumatoid disease and crystal deposition disorders, can produce markedly elevated synovial leukocyte counts.

Because substantial overlap exists between inflammatory and infectious processes, synovial fluid analysis must be interpreted carefully.

Septic Synovial Fluid

Fluid from an infected joint may appear purulent, opaque, or markedly cloudy.

The white blood cell count is frequently very high, with a predominance of polymorphonuclear leukocytes.

Gram stain may identify organisms directly, while culture provides definitive microbiological identification in many cases.

A high cell count strongly raises suspicion for infection but is not completely specific because severe inflammatory and crystalline arthropathies can occasionally produce similarly elevated counts.

Traumatic Effusion

Traumatic joint aspiration may produce bloody synovial fluid or frank hemarthrosis.

This may occur after ligament injury, intra-articular fracture, cartilage injury, or other traumatic damage.

If the aspirated blood separates into a fat-fluid level after standing, an intra-articular fracture should be suspected because marrow fat may have entered the joint.

Imaging

Plain Radiographs

Radiographs are frequently useful when evaluating a joint effusion.

They can identify fractures, degenerative changes, erosions, osteophytes, joint-space narrowing, or other osseous abnormalities.

Imaging is particularly important when trauma is suspected or when the cause of the effusion is uncertain.

Crystal Analysis

Synovial fluid should be examined using polarized light microscopy when a crystal arthropathy is suspected.

Identification of characteristic crystals can distinguish gout from calcium pyrophosphate deposition disease.

Gout

Gout is caused by deposition of monosodium urate crystals within the joint.

Under standard microscopy, the crystals are typically needle-shaped.

With compensated polarized light microscopy, they demonstrate strong negative birefringence.

Identification of intracellular or extracellular urate crystals strongly supports the diagnosis of gout.

Pseudogout

Pseudogout, or calcium pyrophosphate deposition disease, is associated with calcium pyrophosphate crystals.

These crystals are generally shorter and more blunt or rhomboid in shape than monosodium urate crystals.

They characteristically demonstrate weak positive birefringence under compensated polarized light.

Septic Arthritis Findings

Synovial fluid from septic arthritis often contains a very high leukocyte count, frequently exceeding 50,000–100,000 cells/mm³, with a high percentage of polymorphonuclear leukocytes.

Gram staining may demonstrate the causative organism, although a negative Gram stain does not exclude infection.

Synovial fluid should therefore be sent for culture, particularly when clinical suspicion for infection is significant.

Overlap Between Infection and Inflammation

Synovial white cell counts should not be interpreted in isolation.

Severe inflammatory conditions, particularly gout and other crystalline arthropathies, may produce counts within ranges commonly associated with septic arthritis.

Conversely, infection may occasionally occur with lower cell counts, particularly in immunocompromised patients or during early disease.

Clinical findings, cultures, and other investigations remain essential.

Lyme Disease

In selected patients, molecular testing such as polymerase chain reaction or appropriate serologic testing may assist in evaluating suspected Lyme arthritis.

Testing should be guided by the clinical presentation and exposure history.

Differential Diagnosis

The major differential diagnoses for an acute joint effusion include septic arthritis, gout, pseudogout, autoimmune inflammatory disease, trauma, and hemophilia.

Autoimmune causes include conditions such as rheumatoid arthritis and systemic lupus erythematosus.

Clinical history and synovial fluid analysis help distinguish these conditions.

Treatment

General Measures

Treatment is directed toward the underlying cause of the effusion.

Arthrocentesis itself may provide immediate symptomatic benefit by reducing joint pressure and pain.

It may also improve the accuracy of the physical examination by allowing the joint to move more freely after a large effusion has been decompressed.

Traumatic Effusions

Patients with traumatic effusions should be treated according to the underlying injury.

Aspiration may provide pain relief when a large hemarthrosis is present.

The joint should subsequently be assessed for ligamentous injury, fracture, cartilage damage, or other structural abnormalities.

Septic Arthritis

Septic arthritis requires urgent treatment because infection can rapidly destroy articular cartilage.

Synovial fluid and blood cultures should be obtained before antibiotics whenever this can be done without causing harmful delay.

Treatment generally includes appropriate intravenous antibiotics together with adequate joint drainage.

Joint Irrigation and Debridement

Many cases of septic arthritis require operative irrigation and debridement.

The exact method depends on the joint involved, the severity of infection, the causative organism, and the patient’s clinical condition.

Drainage may be performed arthroscopically or through an open approach when necessary.

Inflammatory and Crystal Arthropathies

Patients with inflammatory or crystal-induced arthritis often improve with anti-inflammatory treatment after septic arthritis has been excluded.

Depending on the diagnosis, therapy may include NSAIDs, colchicine, corticosteroids, or disease-specific rheumatologic medications.

Referral to a rheumatologist may be appropriate for recurrent or systemic inflammatory disease.

Arthrocentesis Technique

A strict sterile skin preparation is essential before inserting the aspiration needle.

The joint and surrounding skin should be cleansed thoroughly, and sterile technique should be maintained throughout the procedure.

This is particularly important when aspirating a joint in which infection is already being considered.

Local Anesthesia

A small-gauge needle may be used to infiltrate local anesthetic into the skin and superficial tissues before aspiration.

This can reduce procedural discomfort, especially when a large aspiration needle is required or when more than one attempt may be necessary.

Needle Selection

Synovial fluid can be relatively viscous, particularly in certain inflammatory conditions.

A sufficiently large needle is therefore required for effective aspiration.

An 18-gauge needle or larger is commonly used for large joints such as the knee, although needle size should be adapted to the joint and clinical situation.

Knee Arthrocentesis

The knee is one of the easiest joints to aspirate because large effusions commonly distend the suprapatellar pouch.

A common approach is from the lateral side beneath or adjacent to the patella, directing the needle into the joint space.

A medial approach may also be used depending on clinician preference and the location of the effusion.

Image-Guided Arthrocentesis

Imaging guidance can improve accuracy for deeper or anatomically difficult joints.

Ultrasound is particularly useful because it allows real-time visualization of the effusion, needle, and surrounding structures.

Fluoroscopy or CT guidance may be useful for joints such as the hip or shoulder in selected circumstances.

Follow-Up

After aspiration, the patient should be reassessed for improvement in pain and range of motion.

The puncture site should be observed for bleeding, persistent drainage, or signs of infection.

Laboratory and culture results should be reviewed promptly, particularly when infection was part of the differential diagnosis.

Complications

The most important potential complication is iatrogenic infection of the joint.

Strict sterile technique is therefore mandatory.

Other potential complications include bleeding, pain, damage to nearby tendons or neurovascular structures, and failure to obtain adequate fluid.

Aspiration Through Cellulitis

Whenever possible, a joint should not be aspirated through an area of overlying cellulitis or infected skin.

Passing the needle through infected tissue may introduce bacteria into a previously sterile joint.

An alternative approach through uninvolved skin should be selected when feasible.

Special Consideration in Suspected Septic Arthritis

A potentially infected joint requires particularly careful technique.

Aspiration is nevertheless essential when septic arthritis is suspected because synovial fluid analysis and culture are often central to diagnosis.

The benefit of obtaining diagnostic fluid must therefore be balanced with meticulous sterile preparation and selection of a safe needle path.

Patient Monitoring

Patients should be monitored according to the underlying diagnosis rather than the aspiration alone.

Those with suspected infection require particularly close follow-up until cultures are finalized and clinical improvement is documented.

Patients with recurrent inflammatory or crystal arthropathies may require longer-term rheumatologic management, whereas traumatic effusions should be followed until the associated injury has healed.

Orthopaedic Surgery - Anterior Cruciate Ligament Injury

Basics

The anterior cruciate ligament (ACL) is essential for maintaining knee stability, particularly during athletic activities that involve running, cutting, pivoting, jumping, landing, and kicking.

The ACL originates from the posteromedial aspect of the lateral femoral condyle and inserts on the anterior portion of the tibial plateau between the intercondylar eminences.

It consists of two principal functional bundles: the anteromedial bundle and the posterolateral bundle.

The ACL is the primary restraint to anterior translation of the tibia relative to the femur and also acts as an important secondary restraint to excessive internal rotation of the tibia.

Injury Pattern by Age

The pattern of ACL injury differs between skeletally immature and mature patients.

In children and adolescents with open growth plates, the ligament itself may remain intact while the injury occurs at the bone-ligament interface. This can produce an avulsion fracture of the tibial spine, where the ACL attachment is pulled away with a fragment of bone.

In skeletally mature adults, injury more commonly produces a midsubstance rupture of the ACL.

Epidemiology

ACL injuries are strongly associated with sports that involve rapid changes in direction, deceleration, jumping, landing, or direct contact.

Commonly associated activities include football, hockey, basketball, lacrosse, gymnastics, wrestling, and volleyball.

ACL injuries occur in both contact and noncontact situations, although many occur without direct impact to the knee.

Risk Factors

Female athletes participating in comparable competitive sports have an ACL injury rate approximately 4–6 times higher than male athletes.

The difference is likely multifactorial and may involve anatomical, hormonal, biomechanical, and neuromuscular factors.

Etiology

Several anatomical features have been associated with increased susceptibility to ACL injury.

These include an increased Q angle, narrowing of the femoral intercondylar notch, and a relatively narrow ACL.

Neuromuscular factors are also important. Landing with inadequate knee flexion together with excessive dynamic knee valgus can substantially increase strain on the ACL.

Noncontact Mechanism

Many ACL tears occur through a noncontact mechanism.

A typical injury occurs when an athlete rapidly decelerates, plants the foot, changes direction, pivots, or lands from a jump.

The foot remains fixed while abnormal rotational and translational forces are transmitted across the knee, producing ACL failure.

Contact Mechanism

ACL rupture may also result from direct trauma.

A classic contact mechanism involves a valgus force applied to the knee combined with external rotation of the tibia, such as a clipping injury during contact sport.

This mechanism may also damage other structures, particularly the medial collateral ligament.

Associated Bone Bruising

Bone bruises or trabecular microfractures occur in more than half of acute ACL injuries.

They are typically found on the posterior aspect of the lateral tibial plateau and near the sulcus terminalis of the lateral femoral condyle.

These opposing contusions are sometimes described as a “kissing contusion” pattern.

They are believed to occur when the posterolateral tibial plateau impacts against the lateral femoral condyle during the injury mechanism that ruptures the ACL.

Meniscal Injuries

Meniscal tears accompany more than half of ACL injuries.

During the acute injury, lateral meniscal tears are generally more common than medial meniscal tears.

In a chronically ACL-deficient knee, repeated episodes of instability place greater stress on the medial meniscus. Consequently, medial meniscal tears become more common in chronic ACL deficiency.

Other Associated Injuries

ACL rupture may occur together with other ligamentous injuries.

The medial collateral ligament (MCL) is more frequently injured than the lateral collateral ligament.

Articular cartilage damage may also occur either at the time of the original injury or later as a consequence of recurrent instability.

Diagnosis

Signs and Symptoms

Patients commonly describe immediate knee pain at the time of injury.

Many report hearing or feeling an audible “pop” within the knee.

Rapid swelling usually develops within several hours because of acute hemarthrosis.

The patient often feels that the knee is unstable and may be unable to continue participating in the activity.

Weight-bearing may initially be painful or difficult.

History

The mechanism of injury should be carefully established.

Important historical features include sudden deceleration, pivoting, landing from a jump, a contact valgus injury, or twisting of the knee while the foot was planted.

The presence of a pop, rapid swelling, immediate instability, and inability to continue sporting activity strongly raises suspicion for ACL rupture.

Physical Examination

A careful physical examination can diagnose the majority of ACL injuries.

Findings in the injured knee should always be compared with those of the contralateral normal knee because baseline ligamentous laxity varies between individuals.

Knee Effusion

Inspection commonly reveals a moderate or large knee effusion.

Effusion can be assessed by compressing fluid from the suprapatellar pouch toward the joint while palpating for increased fluid pressure around the knee.

Patellar ballottement may also help identify a significant intra-articular effusion.

Range of Motion

Full knee extension is commonly limited during the acute stage.

This may result from pain, joint effusion, protective hamstring spasm, or mechanical impingement from the torn ACL stump.

Flexion may also be restricted because of swelling and discomfort.

Restoring full extension is particularly important during rehabilitation.

Posterior Sag Consideration

When assessing anterior tibial translation, the examiner should first ensure that the tibia is not sitting abnormally posteriorly because of an associated posterior cruciate ligament injury.

If posterior sag is present, anterior translation during testing may simply return the tibia to a neutral position and falsely suggest excessive anterior laxity.

Lachman Test

The Lachman test is the most sensitive clinical examination for diagnosing an acute ACL tear.

The knee is positioned in approximately 30° of flexion.

The examiner stabilizes the distal femur and applies an anteriorly directed force to the proximal tibia or calf.

The amount of anterior translation and the quality of the endpoint are assessed.

Lachman Test Interpretation

An intact ACL normally produces a firm endpoint.

An ACL-deficient knee generally demonstrates increased anterior tibial translation together with a soft or poorly defined endpoint.

The difference between the injured and uninjured knees is clinically important.

Guarding During Lachman Testing

The Lachman test can be difficult to perform in the acute setting because pain and anxiety may cause involuntary hamstring contraction.

The examiner should support the leg fully, minimize discomfort, and encourage the patient to relax.

Reducing muscle spasm improves the accuracy of the examination.

Pivot Shift Test

The pivot shift test assesses dynamic anterolateral rotational instability of the ACL-deficient knee.

It evaluates anterior subluxation of the lateral tibial plateau relative to the lateral femoral condyle.

The test can be difficult to perform reliably in an awake patient with an acutely painful knee because guarding interferes with the maneuver.

It is often more informative when performed under anesthesia.

Pivot Shift Technique

The patient lies supine with the knee initially extended.

The tibia is placed in internal rotation while the examiner applies a valgus force to the knee as it is slowly flexed.

In an ACL-deficient knee, the lateral tibial plateau begins in an anteriorly subluxated position.

At approximately 20–40° of knee flexion, the iliotibial band causes sudden reduction of the tibia.

A palpable or visible jerk during this reduction constitutes a positive pivot shift.

Anterior Drawer Test

The anterior drawer test is less reliable than the Lachman test for diagnosing an acute ACL injury.

The patient is positioned with the hip flexed to approximately 45° and the knee flexed to 90°.

The examiner grasps the proximal tibia and applies an anteriorly directed force.

The amount of anterior translation and the firmness of the endpoint are assessed and compared with the opposite knee.

Instrumented Laxity Testing

Objective knee laxity can be measured with devices such as the KT-1000 arthrometer.

These devices quantify anterior tibial translation and are useful in research, postoperative assessment, or when objective documentation is required.

They are not necessary for routine diagnosis in most patients.

A side-to-side difference of more than approximately 3 mm in anterior tibial translation is considered abnormal.

Imaging

Plain Radiographs

Initial radiographic evaluation generally includes anteroposterior, lateral, and tunnel views of the knee.

Plain radiographs do not directly demonstrate the ACL but may reveal associated osseous abnormalities that strongly suggest ACL injury.

Tibial Spine Avulsion

A tibial spine avulsion fracture may be seen in skeletally immature patients.

This represents avulsion of the ACL attachment from the tibial eminence rather than midsubstance rupture of the ligament.

The amount of displacement is important in determining treatment.

Segond Fracture

A Segond fracture is a small avulsion fracture involving the lateral aspect of the proximal tibia.

It is strongly associated with ACL rupture and represents injury around the anterolateral capsular or ligamentous structures.

Identification of a Segond fracture should prompt careful evaluation for an ACL injury.

Other Radiographic Findings

Additional radiographic findings suggestive of ACL injury include avulsion involving the anterolateral ligament and deepening of the lateral femoral sulcus or sulcus terminalis.

These findings reflect the mechanism of impaction and rotational instability associated with ACL rupture.

MRI

MRI is the imaging modality of choice for evaluating the ACL and associated intra-articular injuries.

It can demonstrate the ligament directly and assess accompanying bone bruises, meniscal tears, collateral ligament injuries, cartilage damage, and occult fractures.

MRI has an overall diagnostic accuracy of approximately 95% for ACL injury.

MRI in Children

MRI is also highly effective in pediatric patients.

Reported sensitivity is approximately 96%, with specificity around 97% for diagnosing ACL injuries in children.

It is particularly useful for distinguishing a midsubstance ACL injury from tibial spine avulsion or associated meniscal pathology.

MRI Appearance of ACL Tear

On sagittal MRI, an intact ACL normally appears as a continuous low-signal structure extending from the femur to the tibia.

A tear may appear as discontinuity, abnormal orientation, waviness, or increased signal within the ligament.

Associated bone marrow edema often provides additional evidence of the injury mechanism.

Differential Diagnosis

Important differential diagnoses include osteochondral fracture, osteochondritis dissecans, tibial plateau fracture, meniscal injury, and articular cartilage injury.

Other ligamentous injuries that may mimic or accompany ACL rupture include injuries of the MCL, LCL, and PCL.

Initial Stabilization

During the acute period, the injured knee may be supported temporarily with a splint or knee immobilizer.

Crutches can be used for comfort and to reduce painful weight-bearing.

Prolonged immobilization should generally be avoided because early restoration of motion is important.

The primary early rehabilitation goal is to regain full knee range of motion, particularly full extension.

Acute Symptom Control

Ice and elevation help reduce swelling.

Simple analgesics or anti-inflammatory medication may be used for pain control.

Once tolerated, early active knee motion should be encouraged to prevent stiffness.

General Treatment Principles

Treatment decisions are individualized according to several factors.

Important considerations include patient age, activity level, occupational demands, sporting participation, degree of instability, skeletal maturity, and associated meniscal or cartilage pathology.

Activities involving cutting, pivoting, jumping, and rapid directional change place particularly high demands on ACL stability.

Treatment in Skeletally Mature Patients

Treatment options include structured nonoperative rehabilitation or ACL reconstruction.

Nonoperative treatment may be appropriate for older individuals, relatively sedentary patients, or those who can modify their activities and do not experience significant instability.

Reconstruction is more commonly considered in young or active patients who wish to return to pivoting or cutting sports.

Treatment in Skeletally Immature Patients

Management of ACL tears in children requires consideration of the open growth plates.

Historically, some children were treated nonoperatively until skeletal maturity.

However, prolonged instability may contribute to progressive meniscal and articular cartilage injury.

As a result, contemporary treatment increasingly favors carefully selected surgical reconstruction using techniques designed to minimize damage to the physes.

Tibial Spine Avulsion Treatment

Nondisplaced or minimally displaced tibial spine avulsion fractures in skeletally immature patients can often be managed with closed reduction and immobilization with the knee in extension.

More significantly displaced fractures may require operative reduction and fixation to restore ACL tension and joint congruity.

Activity Modification

Patients should be counseled regarding activities that place high rotational loads on the knee.

Sports requiring cutting, pivoting, sudden deceleration, jumping, and landing are particularly likely to produce recurrent instability in an ACL-deficient knee.

Activity modification may be sufficient for some patients treated nonoperatively.

Functional Bracing

The benefit of routine functional knee bracing after ACL injury or reconstruction remains controversial.

Braces may improve confidence in selected patients but do not reliably substitute for normal ligament function, neuromuscular control, or rehabilitation.

Physical Therapy

Rehabilitation is important whether the ACL injury is treated nonoperatively or surgically.

The program should emphasize early restoration of range of motion, particularly full extension, together with early appropriate weight-bearing.

Progressive strengthening is then introduced.

Strengthening

Closed-chain, weight-bearing exercises are commonly used to strengthen the quadriceps and hamstrings while limiting excessive anterior shear across the knee.

The goal is to restore quadriceps and hamstring function to at least approximately 90% of the strength of the opposite limb before unrestricted return to high-level activity.

Preoperative Rehabilitation

Patients selected for ACL reconstruction should ideally regain full knee range of motion and substantially reduce swelling before surgery.

Operating on a stiff, swollen knee increases the risk of postoperative stiffness and arthrofibrosis.

Reconstruction outcomes are generally better when full or near-full motion has been restored before surgery.

Postoperative Rehabilitation

After reconstruction, rehabilitation focuses on restoring motion, strength, proprioception, balance, and neuromuscular control.

Agility and progressive strengthening exercises are commonly introduced around 6 weeks after surgery, although exact timing depends on the reconstruction technique and rehabilitation protocol.

Later stages include running, jumping, cutting, and sport-specific drills.

Medication

During the acute period, pain may be treated with NSAIDs or acetaminophen.

Routine opioid analgesics are generally avoided when symptoms can be adequately controlled with simpler medications.

Surgical Indications

ACL reconstruction is commonly recommended for active individuals who experience functional instability after an acute tear.

It is also indicated in patients with chronic ACL deficiency when recurrent instability threatens the menisci and articular cartilage.

Associated repairable meniscal injury may strengthen the indication for stabilization.

ACL Reconstruction

Modern ACL surgery usually involves intra-articular ligament reconstruction rather than primary repair of a midsubstance tear.

The torn ACL is replaced with a tendon graft positioned to reproduce the function of the native ligament.

Reconstruction may be performed arthroscopically or with combined open techniques when required.

Graft Selection

Graft choice depends on patient age, activity demands, anatomy, surgeon experience, and individual preference.

Both autografts and allografts can be used.

Autograft Options

Common autograft choices include bone-patellar tendon-bone graft, four-strand hamstring tendon graft, and quadriceps tendon graft.

Each has specific advantages and potential donor-site complications.

Autografts are frequently preferred in young and highly active patients.

Allograft Options

Allograft tissue may be obtained from structures including the Achilles tendon, quadriceps tendon, patellar tendon, hamstring tendons, anterior or posterior tibialis tendons, and fascia lata.

An advantage is avoidance of autograft harvest and therefore less donor-site morbidity.

Historically, concerns have included disease transmission and altered graft incorporation, although tissue-processing techniques have greatly reduced transmission risk.

Graft Choice in Young Patients

In children, adolescents, and young active adults, current practice generally favors autograft reconstruction.

Allograft reconstruction in younger patients has been associated with a higher risk of graft failure compared with autograft.

Primary ACL Repair

Primary repair is not generally recommended for a typical adult midsubstance ACL rupture.

However, operative reduction and repair or fixation may be appropriate for a displaced tibial spine avulsion fracture because the ligament itself may remain structurally intact.

Reconstruction in Skeletally Immature Patients

The operative technique in children depends on skeletal maturity.

The goal is to restore knee stability while minimizing the risk of growth-plate injury.

Tanner Stage 1

Patients at Tanner stage 1 have substantial growth remaining.

Physeal-sparing reconstruction techniques are generally preferred to avoid crossing the open growth plates.

Tanner Stage 2

Patients at Tanner stage 2 may be treated with selected partial transphyseal techniques depending on skeletal maturity, growth remaining, and surgeon preference.

Care is taken to minimize the amount of physeal injury.

Tanner Stage 3 and Above

Patients approaching skeletal maturity, typically Tanner stage 3 or higher, may undergo more conventional complete transphyseal ACL reconstruction.

The potential risk to the growth plates becomes lower as skeletal maturity approaches.

Follow-Up

Patients should be followed regularly during rehabilitation to assess swelling, range of motion, knee stability, quadriceps and hamstring strength, and progression of functional activity.

Follow-up is particularly important during the early rehabilitation period to identify patients developing stiffness or muscle weakness.

Prognosis

The prognosis after appropriately selected and well-performed ACL reconstruction is generally excellent.

Most patients regain good stability and are able to return to a high level of function.

However, return to sport depends on successful rehabilitation, restoration of strength and neuromuscular control, associated injuries, and psychological readiness.

Consequences of Chronic ACL Deficiency

An untreated ACL-deficient knee may experience repeated episodes of instability.

Over time, this can increase the risk of meniscal tears and articular cartilage damage.

Development of later symptomatic osteoarthritis may also occur, although the relationship between ACL reconstruction and prevention of osteoarthritis remains complex.

Contralateral ACL Injury

Patients who have sustained one ACL tear have an increased risk of subsequently tearing the ACL in the opposite knee.

This risk is particularly important in younger and highly active athletes.

Neuromuscular training and appropriate return-to-sport criteria are therefore important for both knees.

Recurrent ACL Tear

Graft rupture or recurrent ACL injury can occur after reconstruction.

Higher reinjury rates have been reported among athletes involved in high-demand pivoting sports, including football, gymnastics, and soccer.

Young athletes returning to sport at a high competitive level are particularly vulnerable.

Complications of Nonoperative Treatment

Chronic ACL deficiency is associated with an increased risk of complex meniscal injury.

Repeated instability can progressively damage both the menisci and articular cartilage.

There may also be an increased risk of later osteoarthritis, although the degree to which reconstruction prevents this remains controversial.

Surgical Complications

Potential complications after ACL reconstruction include graft failure, graft impingement, quadriceps weakness, patellofemoral pain, infection, and arthrofibrosis.

Rare complications include deep vein thrombosis, nerve injury, vascular injury, compartment syndrome related to arthroscopic fluid extravasation, and complex regional pain syndrome.

Arthrofibrosis

Arthrofibrosis can produce substantial postoperative stiffness, particularly loss of knee extension.

The risk is increased when surgery is performed on a knee that remains swollen and stiff.

Preoperative restoration of motion and careful postoperative rehabilitation are therefore important preventive measures.

Bone-Patellar Tendon-Bone Graft Complications

Harvesting a bone-patellar tendon-bone autograft may result in anterior knee pain or discomfort while kneeling.

Rare complications include patellar fracture and patellar tendon rupture.

Graft selection should therefore consider the patient’s sporting, occupational, and kneeling requirements.

Patient Monitoring

Patients should generally be reassessed at approximately 4–6-week intervals during important phases of recovery.

Monitoring should focus on restoration of knee extension and flexion, quadriceps and hamstring strength, swelling, stability, gait, and functional progression.

Patients who fall behind expected milestones may require more intensive physical therapy to prevent persistent weakness or stiffness.

Orthopaedic Surgery - Ankylosing Spondylitis

Basics

Ankylosing spondylitis (AS) is a seronegative spondyloarthritis characterized by chronic inflammation affecting the axial skeleton and, to a lesser extent, peripheral joints.

The disease primarily involves the spine and sacroiliac (SI) joints, although the hips and shoulders may also be affected. Any level of the spine can become involved as the disease progresses.

AS affects both synovial and fibrous joints. Persistent inflammation can produce chronic synovitis, erosions, sclerosis, fibrosis, and ultimately ankylosis, resulting in progressive loss of joint and spinal mobility.

Extra-articular manifestations may involve the eyes, cardiovascular system, lungs, skin, and mucous membranes.

Epidemiology

Ankylosing spondylitis most commonly becomes symptomatic in young adults, particularly during the third and fourth decades of life.

The disease has traditionally been recognized more frequently and often more severely in males, although both males and females can be affected.

Initial manifestations developing after the age of approximately 40 years are relatively uncommon.

The precise cause remains unknown, but there is a strong association with genes of the major histocompatibility complex, particularly HLA-B27.

Incidence

The reported frequency of ankylosing spondylitis in North America is approximately 0.1–0.3% of the population.

The likelihood of disease is substantially increased among individuals carrying the HLA-B27 gene.

However, genetic susceptibility alone is insufficient to cause disease, and the majority of HLA-B27-positive individuals never develop ankylosing spondylitis.

First-degree relatives of affected patients also have a significantly increased risk compared with the general population.

Prevalence and HLA-B27

Although ankylosing spondylitis is strongly associated with HLA-B27, fewer than approximately 5% of individuals carrying the gene ultimately develop the disease.

Therefore, the presence of HLA-B27 supports the diagnosis in the appropriate clinical setting but does not by itself establish the diagnosis.

Risk Factors

The principal recognized risk factors are HLA-B27 positivity and a positive family history of ankylosing spondylitis or related spondyloarthritis.

An earlier age of onset is often associated with a more severe disease course.

Genetics

Ankylosing spondylitis has a strong hereditary component.

The concordance rate is substantially higher in identical twins than in fraternal twins, supporting an important genetic contribution.

The strongest association is with HLA-B27, although other major histocompatibility complex genes, including HLA-DRB1 and HLA-B60, have also been implicated.

Additional genetic associations have been reported involving genes such as CYP2D6 and IL-1B.

Despite this strong genetic contribution, environmental and immune factors are also believed to influence whether disease develops.

Pathophysiology

Ankylosing spondylitis is a chronic inflammatory arthropathy that characteristically involves the sacroiliac joints, often bilaterally.

Both synovial and fibrous joints of the axial and peripheral skeleton may become inflamed.

Inflammation can also occur at the sites where tendons and ligaments attach to bone, known as entheses.

Persistent inflammation leads to erosion and structural damage, followed by fibrosis and new bone formation. Over time, this may result in progressive ankylosis of the affected joints and spine.

Disease Course

The onset is usually gradual and insidious.

Patients commonly experience periods of worsening symptoms followed by partial improvement or remission.

Although both sexes are affected, disease has historically been observed to be more severe in males.

Earlier onset is also associated with a greater likelihood of significant structural and functional impairment.

Etiology

The exact cause of ankylosing spondylitis remains unknown.

Genetic susceptibility appears to interact with immune and environmental factors.

Various infectious triggers have been investigated. Klebsiella species have been proposed as a possible contributor, although studies have not established a definitive causal relationship.

There is also evidence of an association between ankylosing spondylitis and inflammation of the small intestine, supporting a possible relationship between intestinal immune responses and axial inflammation.

Associated Conditions

Enthesopathy is common and may present as plantar fasciitis or Achilles tendinitis.

Extra-articular manifestations include acute anterior uveitis and cardiovascular abnormalities such as aortic insufficiency, cardiomegaly, and cardiac conduction disturbances.

Pulmonary abnormalities may develop in advanced disease.

Diagnosis

Signs and Symptoms

Diagnosis is based on the combination of clinical features and imaging findings.

Typical symptoms usually persist for at least 3 months and are characteristic of inflammatory rather than mechanical back pain.

Pain and stiffness generally improve with exercise and do not improve significantly with rest.

Morning stiffness is common and may be prolonged.

Common Clinical Features

Patients may develop progressive restriction of spinal movement, fatigue, and reduced chest expansion.

Weight loss can occur in patients with active systemic inflammation.

Inflammation of the costosternal or costovertebral joints may cause chest discomfort.

Progressive disease can lead to thoracic kyphosis and loss of the normal lumbar lordosis.

Upper-extremity peripheral joint involvement is less common than involvement of the hips and lower limbs.

Pulmonary Manifestations

Advanced disease may be associated with apical pulmonary fibrosis.

Restricted mobility of the costovertebral and costosternal joints can also reduce chest expansion and contribute to restrictive respiratory mechanics.

History

The history often reveals a gradual onset of discomfort involving the lumbosacral spine, buttocks, or hips.

Symptoms commonly begin before the age of 40 years and persist for longer than three months.

A characteristic feature is morning stiffness that improves with physical activity.

Pain frequently improves during exercise but returns after prolonged inactivity.

Physical Examination

Patients may have relatively few abnormal findings early in the disease.

A comprehensive examination should include the musculoskeletal, neurologic, pulmonary, and ocular systems.

Careful assessment of spinal posture and mobility is essential.

Lumbar Spine Examination

Reduced lumbar flexion and extension are common as the disease progresses.

Loss of normal lumbar movement may be subtle initially but becomes more evident with increasing structural involvement.

Spinal stiffness should be compared with age-appropriate expectations.

Sacroiliac Joint Examination

Tenderness may be present over the SI joints.

Provocative maneuvers that stress the sacroiliac region may reproduce the patient’s typical buttock or low-back pain.

However, physical examination alone is not sufficiently specific to confirm sacroiliitis.

Chest Expansion

Chest expansion should be assessed because involvement of the costovertebral and costosternal joints may progressively restrict thoracic excursion.

Decreased expansion can contribute to reduced pulmonary function in advanced disease.

Neurologic Examination

A complete neurologic examination is important, particularly in patients with advanced spinal deformity or suspected fracture.

Any new weakness, numbness, gait disturbance, or bowel or bladder abnormality requires urgent evaluation.

Ocular Examination

Patients should be questioned about eye pain, redness, photophobia, and visual disturbance because these symptoms may indicate acute anterior uveitis.

Recurrent uveitis is a well-recognized extra-articular manifestation of ankylosing spondylitis.

Laboratory Tests

HLA-B27

Testing for HLA-B27 can support the diagnosis in a patient with compatible clinical findings.

However, because many healthy individuals carry the gene without developing disease, it should not be interpreted in isolation.

Inflammatory Markers

The erythrocyte sedimentation rate (ESR) may be elevated and can reflect inflammatory activity.

Other inflammatory markers such as C-reactive protein may also be elevated.

However, normal inflammatory markers do not exclude ankylosing spondylitis.

Rheumatoid and Antinuclear Antibodies

Rheumatoid factor and antinuclear antibodies are generally not useful for diagnosing ankylosing spondylitis.

The condition is classified as a seronegative spondyloarthritis, meaning rheumatoid factor is typically absent.

Imaging

Plain Radiographs

Radiographs may remain normal during the early stages of disease.

As ankylosing spondylitis progresses, characteristic abnormalities develop, particularly around the sacroiliac joints.

Sacroiliac Joint Findings

Radiographic changes of the SI joints are central to the diagnosis of established ankylosing spondylitis.

Changes are typically bilateral and relatively symmetric.

Early abnormalities include erosions and subchondral sclerosis, producing irregular or poorly defined joint margins.

Apparent widening of the SI joint may occur because erosions create a pseudo-widened appearance.

Late Sacroiliac Changes

With progression, fibrosis and new bone formation lead to narrowing and eventually complete osseous bridging or ankylosis of the SI joints.

These findings indicate advanced structural disease.

Spinal Radiographic Findings

Inflammation at the vertebral margins and outer annulus fibrosus leads to erosive changes followed by new bone formation.

Bridging syndesmophytes may progressively connect adjacent vertebral bodies.

When extensive, this produces the characteristic radiographic appearance known as a “bamboo spine.”

Bamboo Spine

The bamboo-spine appearance results from progressive ossification and syndesmophyte formation across multiple vertebral levels.

The spine becomes increasingly rigid and behaves biomechanically more like a long bone than a flexible segmented column.

This rigidity substantially increases the risk of unstable spinal fractures.

Imaging for Suspected Fracture

Fractures in ankylosed spines can be difficult to identify on standard radiographs.

Anteroposterior, lateral, and appropriate additional views should be examined carefully.

When fracture is suspected, CT with multiplanar or 3D reconstruction is highly useful because it is more sensitive for detecting fracture lines and defining their extent.

MRI

MRI is particularly valuable when neurologic symptoms are present or when an occult fracture or soft-tissue complication is suspected.

It can identify epidural hematoma, spinal cord compression, ligamentous injury, and other neural abnormalities.

MRI is also useful for detecting active inflammatory sacroiliitis before structural radiographic changes become obvious.

Differential Diagnosis

The differential diagnosis includes other seronegative spondyloarthropathies.

Important conditions include reactive arthritis, psoriatic arthritis, and inflammatory bowel disease-associated arthritis related to Crohn disease or ulcerative colitis.

Additional Differential Diagnoses

Other conditions that may resemble ankylosing spondylitis include septic sacroiliitis, osteoarthritis, rheumatoid arthritis, and lumbar disc herniation.

Clinical history, imaging findings, laboratory studies, and the distribution of joint involvement help distinguish these disorders.

Treatment

Initial Management

The foundation of treatment is regular exercise and maintenance of spinal mobility.

Back exercises and flexibility training help reduce pain, maintain function, and limit progressive loss of motion.

Exercise should begin early and continue throughout the course of the disease.

General Measures

Patients should be encouraged to maintain an active and healthy lifestyle whenever possible.

Regular recreational activity helps preserve cardiovascular fitness, muscle strength, posture, and spinal mobility.

Prolonged inactivity should be avoided because stiffness often worsens when movement is reduced.

Posture

Postural training is important because progressive ankylosis may fix the spine in a kyphotic position.

Patients should be encouraged to maintain an upright posture during daily activities and sleep.

Appropriate exercises can help preserve extension and limit progressive flexion deformity.

Physical Therapy

Physical therapy is a central component of management.

Programs should focus on spinal flexibility, posture, chest expansion, strengthening, and maintenance of functional mobility.

Hyperextension exercises may help reduce the tendency toward progressive thoracic kyphosis.

Flexibility Training

Regular stretching and mobility exercises can decrease stiffness and improve functional ability.

Consistent flexibility training may also improve quality of life by helping patients maintain independence and activity.

Medication

First-Line Therapy

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as first-line pharmacologic treatment.

They can reduce pain and stiffness and improve function.

Selection is largely based on patient response and tolerance because no single NSAID, including selective COX-2 inhibitors, has consistently demonstrated clear superiority.

Additional Medical Therapy

Other medications may be considered when symptoms remain inadequately controlled.

Historically, agents such as corticosteroids and sulfasalazine have been used in selected cases, particularly when peripheral joint disease is present.

Systemic corticosteroids are generally not preferred for routine long-term axial disease because of their adverse-effect profile.

Biologic Therapy

Biologic agents that inhibit tumor necrosis factor-alpha (TNF-α) can substantially reduce disease activity in patients with persistent active disease despite conventional treatment.

These medications have become an important treatment option for moderate-to-severe ankylosing spondylitis.

Other targeted biologic therapies may also be used depending on disease characteristics and response.

Other Therapies

A variety of additional agents, including older treatments such as pamidronate and thalidomide, have been investigated.

These are not generally considered routine first-line therapies.

Antibiotics are not routinely indicated because no infectious organism has been established as the direct cause of ankylosing spondylitis.

Surgical Management

Surgery does not treat the underlying inflammatory disease itself.

Instead, surgery is used primarily to manage structural complications that develop as a consequence of long-standing disease.

Total Hip Arthroplasty

Severe hip involvement may lead to painful stiffness and major functional impairment.

Total hip arthroplasty is one of the most commonly performed orthopedic procedures in patients with advanced ankylosing spondylitis.

It can significantly improve pain, mobility, and quality of life.

Spinal Fracture Stabilization

Fractures of an ankylosed spine are often highly unstable.

Because the rigid spine behaves like a long lever arm, even apparently minor fractures may extend through all spinal columns.

Operative stabilization is frequently required to prevent displacement and neurologic deterioration.

Corrective Spinal Osteotomy

Advanced ankylosing spondylitis may produce severe fixed kyphotic deformity.

When deformity markedly limits forward vision, standing balance, or daily function, a corrective spinal osteotomy may be considered.

These procedures are complex and require careful preoperative planning.

Follow-Up

Patients require regular long-term follow-up to assess disease activity, posture, spinal mobility, neurologic function, and extra-articular complications.

Ongoing review also provides an opportunity to reinforce exercise and postural programs and adjust pain medication.

Prognosis

The disease course varies considerably among patients.

Individuals with early-onset disease and prominent peripheral joint inflammation may experience a more severe clinical course.

There is no definitive cure, but modern medical treatment, exercise, and prevention of complications can substantially reduce disability.

Spinal Fracture Risk

One of the most serious complications is spinal fracture after relatively minor trauma.

The ankylosed spine is rigid and brittle and cannot absorb energy in the same way as a normal flexible spine.

As a result, fractures may occur after falls or trauma that would otherwise be considered minor.

Neurologic Complications

Spinal fractures may displace and injure the spinal cord or nerve roots.

Delayed neurologic deterioration can occur if an initially unrecognized fracture subsequently shifts.

Any suspected fracture should therefore be treated as potentially unstable until adequately evaluated.

Epidural Hematoma

Cervical spinal fractures may be associated with an epidural hematoma.

The hematoma can compress the spinal cord and produce rapidly progressive neurologic impairment.

MRI is particularly useful for identifying this complication.

Failure to recognize spinal cord compression may result in permanent paralysis.

Management of Spinal Fractures

Spinal fractures in ankylosing spondylitis require urgent stabilization.

Treatment may involve external immobilization or internal fixation depending on fracture configuration, alignment, neurologic status, and patient factors.

Because these fractures are frequently unstable, surgical fixation is often required.

Uveitis

Acute anterior uveitis develops in a significant proportion of patients, historically reported in approximately 25%.

Symptoms include painful red eye, photophobia, and visual disturbance.

Prompt ophthalmologic assessment is important, and treatment may include topical corticosteroids and other ophthalmic therapies.

Cardiovascular Complications

Potential cardiovascular manifestations include aortic regurgitation, cardiac enlargement, and abnormalities of the cardiac conduction system.

Patients with suggestive symptoms should undergo appropriate cardiovascular evaluation.

Pulmonary Complications

Restrictive respiratory impairment may develop because of reduced chest wall mobility.

Rarely, advanced disease may be associated with upper-lobe pulmonary fibrosis.

Respiratory symptoms should therefore be assessed during long-term follow-up.

Patient Monitoring

Patients should undergo regular review, commonly around every 6 months, although the interval should be individualized according to disease activity.

Monitoring should include posture, spinal mobility, exercise adherence, pain control, and neurologic function.

Patients should also be assessed for extra-articular complications, particularly uveitis and cardiovascular or pulmonary abnormalities.

Early recognition and treatment of complications can substantially reduce long-term morbidity.