Orthopaedic Surgery - Trigger Finger

Basics

Trigger finger is a form of:

Stenosing flexor tenosynovitis

that causes painful:

Catching

Clicking

or

Locking

of a digit during flexion and extension.

The condition develops when normal gliding between the:

Flexor tendon

and its surrounding:

Tendon sheath

becomes impaired.

Pathophysiology

The most common site of mechanical obstruction is the:

A1 pulley.

A thickened flexor tendon or tendon nodule passes with difficulty through this relatively narrowed pulley, producing:

Triggering.

Self-Perpetuating Mechanism

Repeated catching produces additional:

Mechanical irritation

and

Tendon swelling.

This may further worsen the mismatch between the tendon and:

A1 pulley.

Tendinopathy Rather Than Tendinitis

Histologic studies generally demonstrate:

Degenerative tendon and pulley changes

rather than prominent inflammatory-cell infiltration.

Therefore, adult trigger finger is more accurately considered a:

Stenosing tendinopathy

than a true inflammatory:

Tendinitis.

Quinnell Classification

Trigger finger severity may be graded using the:

Quinnell classification.

Grade 0

Pain with movement

without mechanical:

Catching or triggering.

Grade 1

There is:

Uneven movement

or

Clicking during flexion

but no true locking.

Grade 2

The digit:

Triggers

but the patient can actively:

Correct or extend it.

Grade 3

The digit triggers or locks and requires:

Passive correction

using the opposite hand.

Grade 4

The digit is:

Locked

or has developed a fixed:

Flexion contracture.

Pediatric Triggering

Pediatric trigger thumb and trigger fingers are now regarded as predominantly:

Acquired

rather than truly:

Congenital.

Their underlying mechanism differs from typical adult trigger finger.

Epidemiology

Triggering can involve:

Any digit.

Adults

In adults, the most commonly affected digits are:

Thumb

Ring finger

and

Middle finger.

Children

In children, the:

Thumb

is affected most frequently.

The:

Middle finger

is among the more frequently involved non-thumb digits.

Age

Trigger finger is particularly common in:

Middle-aged adults.

Pediatric cases usually present during:

Early childhood.

Sex

Adult trigger finger is more common in:

Women

than in men.

Incidence

The lifetime incidence in adults is approximately:

2.6%.

Diabetes

Among patients with diabetes, the incidence is substantially higher, historically reported around:

4–10%.

Multiple-digit involvement is also more common in:

Diabetes.

Pediatric Incidence

Pediatric trigger thumb occurs in approximately:

1–3 per 1,000 children.

Pediatric trigger fingers are much less common and have been reported to occur roughly:

10 times less frequently

than pediatric trigger thumb.

Pregnancy

Triggering may occur more frequently during:

Pregnancy

because of soft-tissue and fluid-related changes.

Symptoms may improve after:

Pregnancy.

Risk Factors

Important risk factors include:

Increasing age

Diabetes mellitus

and

Rheumatoid arthritis.

Other Associated Disorders

Trigger finger may also be associated with:

Gout

and other systemic conditions affecting:

Connective tissue or tendon sheaths.

Etiology

In adults, a thickened area or nodule may develop in the:

Flexor tendon.

Mechanical Impingement

The thickened tendon catches as it passes beneath the:

A1 pulley

at the level of the:

MCP joint.

Triggering

As the patient flexes and extends the digit, the tendon may suddenly pass through the narrowed pulley, producing:

Snapping

or

Locking.

Pediatric Trigger Thumb

In children approximately:

1–4 years of age

a nodular thickening of the flexor pollicis longus may be present.

This is commonly called a:

Notta node.

Notta Node

A Notta node may be palpable near the:

MCP flexion crease

and can prevent smooth passage of the tendon through the:

A1 pulley.

Pediatric Trigger Finger

Non-thumb trigger digits in children have a more complex and less well-understood:

Etiology.

Possible abnormalities include:

Anomalous lumbrical insertion into the flexor digitorum superficialis

or an abnormal relationship between the:

FDS

and

FDP tendons.

Associated Conditions in Children

Pediatric trigger fingers may be associated with:

Mucopolysaccharidoses

Juvenile idiopathic arthritis

Ehlers-Danlos syndrome

and

Down syndrome.

Associated Conditions in Adults

Adults may have associated conditions such as:

Carpal tunnel syndrome

or

de Quervain tenosynovitis.

Diagnosis

Trigger finger is primarily a:

Clinical diagnosis.

Signs and Symptoms

Typical findings include:

Pain

Tenderness

Clicking

and

Locking.

Palmar Nodule

A palpable nodule may be present along the:

Flexor tendon

near the:

Distal palmar crease.

A1 Pulley Tenderness

Tenderness is usually maximal over the:

A1 pulley.

Painful Locking

The digit may become locked in:

Flexion

and then release suddenly during:

Extension.

Snapping

Patients may describe a painful:

Snap

or

Pop

during movement.

Radiation of Pain

Pain may occasionally radiate proximally into the:

Palm

or

Forearm.

Physical Examination

Palpate the flexor tendon sheath at the level of the:

A1 pulley

while asking the patient to repeatedly:

Flex and extend the digit.

Palpable Triggering

The examiner may feel:

Tendon thickening

A nodule

or the actual:

Triggering event.

Examine All Digits

All digits should be examined because:

Multiple trigger digits

may occur, particularly in patients with systemic:

Disease.

Bilateral Pediatric Disease

Approximately:

25% of pediatric trigger-thumb cases

may have bilateral involvement.

Fixed Contracture

Chronic disease may produce a fixed:

PIP or IP flexion contracture.

Laboratory Tests

No serum laboratory study is specific for:

Trigger finger.

Systemic Disease Evaluation

Laboratory investigation is not routinely required but may be appropriate when an underlying systemic disorder such as:

Rheumatoid arthritis

Gout

or another metabolic disease is suspected.

Imaging

Imaging is usually:

Unnecessary.

Radiographs

Plain radiographs may be helpful when a fixed deformity raises concern for:

Arthritis

Joint contracture

Loose body

or other:

Bony pathology.

Ultrasound

Ultrasound can demonstrate thickening of the:

Flexor tendon

or

A1 pulley

but is not routinely required for diagnosis.

Differential Diagnosis

Important alternatives include:

Flexor tendon rupture

Joint contracture or ankylosis

Congenital clasped thumb

Extensor tendon deficiency

Tumor of the tendon sheath

and

Loose body within the MCP joint.

Treatment

Management depends on:

Age

Severity

Number of involved digits

and whether symptoms are:

Adult or pediatric in origin.

General Measures

Mild symptoms may temporarily improve with:

Rest

and

Activity modification.

Multiple Trigger Digits

Multiple symptomatic trigger digits may suggest:

Systemic disease

and may increase the likelihood that:

Surgical treatment

will eventually be required.

Pediatric Trigger Thumb

Many pediatric trigger thumbs may resolve:

Spontaneously.

Resolution may take as long as:

Several years.

Observation in Children

Observation is appropriate in selected young children without:

Fixed deformity

or progressive:

Contracture.

Timing of Pediatric Surgery

Persistent pediatric trigger thumb may require surgery, particularly when there is:

Fixed IP flexion contracture

or failure to improve with:

Growth.

Historically, release has often been considered before approximately:

4 years of age

when contracture is persistent.

Pediatric Trigger Finger

Non-thumb pediatric trigger fingers may be treated initially with:

Observation

or

Splinting

but are more likely than trigger thumb to involve:

Complex tendon abnormalities.

Adult Trigger Finger

In adults, first-line treatment commonly includes:

Corticosteroid injection.

Splinting

Splinting may be useful for:

Mild cases

particularly when the patient can comply consistently with:

Orthotic use.

Activity After Injection

Routine activity restrictions are usually unnecessary after:

Corticosteroid injection

although temporary avoidance of painful repetitive use may improve:

Comfort.

Physical Therapy

Formal physical therapy is generally:

Not required.

Hand Therapy

Selected patients may benefit from instruction regarding:

Splinting

Tendon gliding

and

Activity modification.

Medication

The principal medication treatment in adults is:

Corticosteroid injection.

Injection Technique

Corticosteroid, often combined with:

Local anesthetic

is injected into or adjacent to the:

Flexor tendon sheath

at the level of the:

A1 pulley.

Avoid Intratendinous Injection

Medication should not be injected directly into the:

Flexor tendon

because this may increase the risk of:

Tendon injury or rupture.

Injection Success

A single corticosteroid injection has historically produced improvement in approximately:

45–92% of patients.

Factors Associated With Injection Failure

Injection is less likely to succeed in patients with:

Diabetes

Multiple trigger digits

and sometimes younger patients with:

Long-standing symptoms.

Injection Complications

Potential complications include:

Skin depigmentation

Subcutaneous fat atrophy

Transient hyperglycemia

and, rarely,

Tendon attrition or rupture.

Surgery

Surgical release is indicated when symptoms persist despite appropriate:

Nonoperative treatment

or when the digit is:

Fixed or severely locked.

A1 Pulley Release

The standard procedure is:

Release of the A1 pulley.

Open Release

Open surgical release remains the most established and reliable:

Procedure.

Surgical Incision

A small:

Longitudinal

Transverse

or

Oblique incision

is made over the affected:

A1 pulley.

Pulley Division

The A1 pulley is carefully divided while protecting the adjacent:

Digital nerves

and

Digital vessels.

Persistent Triggering

If triggering persists after complete A1 pulley release, selected patients may require excision of the:

Ulnar slip of the FDS tendon.

Percutaneous Release

Some surgeons use:

Percutaneous A1 pulley release

in appropriately selected:

Adult patients.

Pediatric Trigger Finger Surgery

Pediatric non-thumb trigger fingers may require more extensive procedures, including:

Partial A2 pulley release

A3 pulley release

or

FDS slip excision.

Pediatric Trigger Thumb Surgery

Trigger-thumb release requires particular care because the:

Radial digital nerve

crosses near the operative:

Field.

Postoperative Care

The hand is usually covered with a:

Light dressing

for several days.

Motion

Early:

Finger motion

is generally encouraged after surgery to prevent:

Stiffness.

Activity

Normal activity is resumed:

Gradually

as wound healing and comfort permit.

Follow-Up

Follow-up after injection is based on:

Persistence or recurrence of symptoms.

After Surgery

After uncomplicated release, prolonged monitoring is usually:

Not necessary.

Prognosis

Overall prognosis is:

Good to excellent.

Corticosteroid Injection

Injection is less successful in patients with:

Diabetes mellitus

and may also be less effective when several digits are involved.

Surgical Success

Open A1 pulley release has a reported success rate exceeding:

97%.

Pediatric Prognosis

Open release provides highly reliable outcomes in:

Pediatric trigger thumb

and

Pediatric trigger finger.

Pediatric Recurrence

Recurrence after surgery is more common in pediatric:

Trigger fingers

than in pediatric:

Trigger thumbs.

Complications

Potential injection complications include:

Digital nerve injury

Vascular injury

Tendon injury

and

Skin changes.

These are generally:

Uncommon.

Surgical Complications

Potential surgical complications include:

Digital nerve laceration

Flexor tendon injury

Infection

Stiffness

Persistent triggering

and

Complex regional pain syndrome.

Recurrence

Incomplete release of the:

A1 pulley

or unrecognized additional pathology may lead to:

Persistent or recurrent triggering.

Patient Monitoring

Following successful surgical release, extensive long-term monitoring is usually:

Unnecessary.

Patients should return if they develop:

Recurrent triggering

Wound problems

Neurologic symptoms

or persistent:

Stiffness.

Clinical Summary

Typical presentation: Painful clicking, catching, or locking of a finger during flexion and extension, with tenderness over the A1 pulley.

Key pathology: Thickening of the flexor tendon and/or A1 pulley causes impaired tendon gliding.

Most commonly affected adult digits: Thumb, ring finger, and middle finger.

Diagnosis: Primarily clinical; imaging and laboratory tests are usually unnecessary.

First-line adult treatment: Corticosteroid injection into or around the flexor tendon sheath, with splinting as an option in mild cases.

Surgery: A1 pulley release is indicated for persistent, recurrent, fixed, or severe triggering and has a very high success rate.

Pediatric trigger thumb: Often observed initially because spontaneous resolution can occur, but persistent fixed contracture may require surgical release.

Important association: Trigger finger is more common and often more resistant to injection in patients with diabetes mellitus.

Key Principle

Trigger finger is a stenosing flexor tenosynovial disorder caused by impaired passage of the flexor tendon through the A1 pulley.

The characteristic findings are:

Tenderness over the A1 pulley, a palpable tendon nodule, and painful clicking, catching, or locking.

Diagnosis is almost always:

Clinical.

In adults, treatment usually begins with:

Corticosteroid injection, while persistent or severe disease is treated with:

A1 pulley release.

Children, particularly those with:

Trigger thumb, have a different natural history and may initially be observed, but persistent fixed contracture warrants:

Surgical evaluation.

Orthopaedic Surgery - Triangular Fibrocartilage Complex Tear

Basics

The:

Triangular fibrocartilage complex

or

TFCC

is a group of ligamentous and fibrocartilaginous structures located on the:

Ulnar side of the wrist.

It is an important stabilizer of the:

Distal radioulnar joint

during:

Pronation

and

Supination.

Load Transmission

The TFCC also contributes to transmission of axial load across the:

Ulnocarpal wrist.

Approximately:

20% of load across the wrist

may normally be transmitted through the:

Ulnar-sided structures.

Anatomy

The TFCC extends broadly between the:

Distal radius

and

Ulna

with attachments extending from the region of the:

Ulnar styloid and fovea

toward the:

Sigmoid notch of the distal radius.

Components

The TFCC includes the:

Triangular fibrocartilage disc proper

Dorsal distal radioulnar ligament

Volar distal radioulnar ligament

Meniscus homolog

Ulnar collateral ligament

Ulnotriquetral ligament

Ulnolunate ligament

and

Extensor carpi ulnaris tendon subsheath.

Deep Component

The deep portion of the radioulnar ligament complex inserting into the:

Ulnar fovea

has historically been termed the:

Ligamentum subcruentum.

This component is especially important for:

Distal radioulnar joint stability.

Meniscal Variant

Some wrists contain a true:

Meniscal-like structure

with a free edge that may be visible during:

Arthroscopy.

Clinical Importance

TFCC injury may produce:

Acute

or

Chronic ulnar-sided wrist pain.

Symptoms are often aggravated by:

Forearm rotation

Grip

and

Axial loading.

Classification

The:

Palmer classification

divides TFCC lesions into:

Traumatic Class 1

and

Degenerative Class 2 injuries.

Palmer Class 1

Class 1 lesions are:

Traumatic.

Type 1A

Type 1A is a:

Central perforation.

Because the central TFCC is relatively:

Avascular

these tears have limited spontaneous healing capacity.

Type 1B

Type 1B is a tear of the:

Ulnar attachment.

These peripheral injuries may involve the:

Foveal or styloid attachment

and can produce:

Distal radioulnar joint instability.

Type 1C

Type 1C represents detachment of the TFCC from its:

Carpal attachment

including injury to the:

Volar ulnocarpal ligaments.

Type 1D

Type 1D is a tear involving the:

Radial attachment

of the TFCC.

Palmer Class 2

Class 2 lesions are:

Degenerative.

They often result from chronic:

Ulnocarpal loading

and may be associated with:

Positive ulnar variance.

Ulnar Positive Variance

When the ulna projects farther distally than expected relative to the radius, increased loading across the:

TFCC

and

Ulnocarpal joint

may contribute to:

Degenerative tearing.

Epidemiology

TFCC tears are increasingly recognized because of improvements in:

Clinical examination

MRI

and

Wrist arthroscopy.

Age

Symptomatic tears are commonly encountered between approximately:

30 and 60 years of age.

Risk Factors

Activities that repeatedly load the wrist during:

Pronation-supination

Radial-ulnar deviation

or

Heavy lifting

increase stress on the:

TFCC.

Sports and Occupational Exposure

Examples include activities involving:

Racquet sports

Gymnastics

Weight lifting

Manual labor

or repetitive:

Forearm rotation.

Etiology

Traumatic tears may result from forceful:

Hyperpronation

or

Wrist dorsiflexion.

Mechanism

A fall onto the hand or twisting injury can produce excessive stress across the:

TFCC

and

Distal radioulnar joint.

Associated Fractures

TFCC injury may occur with fractures of the:

Distal radius

Distal ulna

or both bones.

Distal Radioulnar Joint

A major TFCC tear may function biomechanically like disruption of the:

Distal radioulnar stabilizers

and produce:

DRUJ instability.

Diagnosis

Diagnosis is based on:

History

Focused physical examination

and

Imaging.

Arthroscopy

Wrist arthroscopy remains the:

Gold standard

for directly identifying and characterizing a:

TFCC tear.

However, many patients can initially be evaluated using:

Clinical examination and MRI.

Signs and Symptoms

The most common complaint is:

Ulnar-sided wrist pain.

Provocative Activities

Pain is often worsened by:

Pronation

Supination

Gripping

and

Axial loading of the wrist.

Trauma History

Many patients recall a specific:

Traumatic event.

Others, particularly those with degenerative tears, may describe more gradual:

Symptom onset.

Clicking

Patients may experience:

Clicking

Snapping

or

Catching

particularly during:

Forearm rotation.

Physical Examination

The examination should carefully localize the source of:

Ulnar-sided wrist pain.

Range of Motion

Assess wrist and forearm:

Flexion

Extension

Radial deviation

Ulnar deviation

Pronation

and

Supination.

Crepitus and Snapping

Examine for:

Crepitus

Clicking

Painful snapping

and

Instability.

TFCC Compression Test

The TFCC compression test is a provocative maneuver.

The examiner applies:

Axial load

while rotating the:

Ulnar-deviated wrist.

Positive Compression Test

Reproduction of:

Ulnar-sided pain

or a painful:

Click

supports TFCC or ulnocarpal pathology.

Foveal Tenderness

Tenderness in the soft spot between the:

Ulnar styloid

and

Flexor carpi ulnaris tendon

near the ulnar fovea may support a:

Peripheral TFCC injury.

DRUJ Examination

Assess the distal radioulnar joint for:

Translation

Pain

and

Instability

in:

Neutral

Pronation

and

Supination.

ECU Examination

The:

Extensor carpi ulnaris tendon

should be palpated during wrist flexion-extension and:

Pronation-supination.

This helps identify:

ECU tendinitis

or

ECU tendon subluxation

as alternative causes of:

Ulnar-sided pain.

Imaging

Plain Radiographs

Standard:

AP

and

Lateral wrist radiographs

are obtained initially.

Purpose of Radiographs

Radiographs help identify:

Fracture

Arthritis

Malalignment

and abnormalities of:

Ulnar variance.

DRUJ Instability

Radiographs obtained in different forearm positions may occasionally help assess:

Distal radioulnar joint alignment.

Ulnar Variance

Ulnar variance should be measured on appropriately positioned:

Neutral-rotation radiographs.

A standardized:

90-90 view

may also be used, with the shoulder abducted approximately 90° and the elbow flexed:

90°.

CT

CT of both wrists may help assess:

DRUJ congruity

and

Rotational instability

particularly when comparison with the contralateral side is useful.

MRI

MRI is commonly used for detailed evaluation of:

TFCC morphology

and associated:

Wrist pathology.

3-Tesla MRI

High-resolution:

3-Tesla MRI

may improve visualization of:

TFCC tears.

MR Arthrography

MR arthrography may be useful when conventional MRI is:

Equivocal.

Arthrography

A full-thickness TFCC tear may permit contrast to pass between the:

Radiocarpal joint

and

Distal radioulnar joint.

Normally, these spaces do not freely:

Communicate.

Differential Diagnosis

The differential diagnosis for ulnar-sided wrist pain includes:

Distal radius fracture

Distal ulna fracture

Carpal fracture

ECU tendinitis

ECU subluxation

FCU tendinitis

Lunotriquetral ligament injury

Ulnocarpal arthritis

Pisotriquetral arthritis

DRUJ arthritis

Ulnar impaction syndrome

and

Ulnar artery thrombosis.

Treatment

Treatment depends on:

Traumatic versus degenerative origin

Fracture association

DRUJ stability

Tear location

and

Ulnar variance.

Associated Fracture

If a TFCC injury occurs with a distal forearm fracture, the fracture should first be:

Reduced and stabilized.

DRUJ Assessment

After reduction of a distal radius or ulna fracture, the:

Distal radioulnar joint

should be checked for:

Congruity and stability.

Acute Repair With Fracture Surgery

When operative fracture fixation is required and significant TFCC instability remains, acute:

TFCC repair

may be performed.

Injury Without Fracture

Initial treatment for an isolated stable TFCC injury is usually:

Nonoperative.

Immobilization

A:

Below-elbow cast or brace

may be used with the forearm near:

Neutral rotation.

Duration

Immobilization may continue for approximately:

4–6 weeks

depending on symptoms and:

Stability.

Long-Arm Immobilization

When control of:

Pronation and supination

is particularly important, some clinicians use:

Long-arm immobilization

or a brace that limits:

Forearm rotation.

Analgesia

Short-term:

Analgesic medication

may be used during the acute phase.

Range of Motion

After immobilization, gentle:

Wrist

and

Forearm range of motion

is gradually reintroduced.

Corticosteroid Injection

In chronic stable TFCC pain, a:

Corticosteroid injection

may provide temporary:

Symptom relief.

Persistent Symptoms

Continued:

Pain

or

Instability

despite adequate conservative treatment should prompt further:

Assessment

and consideration of:

Surgery.

Physical Therapy

Hand therapy is useful when injury or immobilization has caused:

Wrist stiffness

or reduced:

Forearm rotation.

Rehabilitation Goals

Therapy focuses on restoring:

Wrist ROM

Pronation-supination

Grip strength

and controlled return to:

Activity.

Medication

Oral analgesics are generally required only during the:

Acute symptomatic period.

Surgery

Surgical treatment depends heavily on:

Tear location

and whether the DRUJ is:

Stable or unstable.

Peripheral TFCC Tear

A repairable peripheral tear may be treated with:

Arthroscopic

or

Open repair.

Healing Potential

Peripheral TFCC tissue has a better:

Blood supply

than the central disc.

Therefore, peripheral tears are more suitable for:

Repair.

Central Tear

Central TFCC tears without instability are generally treated with:

Arthroscopic debridement

rather than:

Repair.

Reason for Debridement

The central TFCC is relatively:

Avascular

and has limited capacity for:

Biologic healing.

Ulnar Positive Variance

When degenerative tearing is associated with substantial:

Positive ulnar variance

treatment may need to reduce:

Ulnocarpal loading.

Ulnar Shortening Osteotomy

An:

Ulnar shortening osteotomy

may be performed to decrease:

Ulnocarpal contact pressure

and unload the:

TFCC.

Wafer Procedure

When only a small amount of shortening is required, typically less than approximately:

2–3 mm

a:

Wafer procedure

may be considered.

DRUJ Reconstruction

Chronic instability with irreparable TFCC tissue may require reconstruction of the:

Distal radioulnar joint stabilizers

using:

Tendon graft

or

Fascial tissue.

Advanced DRUJ Arthritis

In severe cases with advanced:

Distal radioulnar arthritis

a salvage procedure may be required.

Sauvé-Kapandji Procedure

One option is the:

Sauvé-Kapandji procedure

which combines:

DRUJ arthrodesis

with creation of a proximal ulnar:

Pseudoarthrosis

to preserve:

Forearm rotation.

Follow-Up

Postoperative immobilization varies according to:

Repair type

and

Stability.

Immobilization Duration

Patients may be immobilized for approximately:

2–8 weeks

after surgery.

Rehabilitation

After sufficient healing, therapy progresses through:

Range of motion

Strengthening

and

Functional loading.

Return to Sports

Return to unrestricted sports is often expected at approximately:

5–6 months

after major repair, although timing depends on:

Healing

Strength

and

Procedure performed.

Prognosis

The overall prognosis is generally:

Fair to good.

Persistent Pain

Some patients continue to experience:

Ulnar-sided wrist pain

despite adequate:

Treatment.

Long-Term Degeneration

Posttraumatic degenerative change may develop:

Years or decades

after the initial injury.

Complications

Potential complications of surgery include:

Infection

Nerve injury

Iatrogenic cartilage damage

Tendon injury

Persistent pain

and

Complex regional pain syndrome.

Persistent Instability

Failure of repair or unrecognized deep foveal injury may lead to persistent:

DRUJ instability.

Stiffness

Prolonged immobilization may result in:

Wrist stiffness

or loss of:

Pronation-supination.

Clinical Summary

Typical presentation: Ulnar-sided wrist pain after trauma or repetitive loading, often worsened by pronation-supination, gripping, or axial loading.

Key anatomy: The TFCC stabilizes the distal radioulnar joint and transfers part of the load across the ulnar wrist.

Key examination: Localize ulnar-sided tenderness, perform the TFCC compression test, assess DRUJ stability, and examine the ECU tendon.

Imaging: Start with AP and lateral wrist radiographs and assess ulnar variance; MRI is useful for soft-tissue evaluation, while arthroscopy remains the diagnostic gold standard.

Treatment: Stable injuries are initially treated with immobilization, analgesia, and gradual rehabilitation.

Surgery: Peripheral tears may be repaired, whereas central avascular tears are usually arthroscopically debrided.

Positive ulnar variance: Degenerative tears associated with ulnar impaction may require ulnar shortening or a wafer procedure.

Main complications: Persistent pain, DRUJ instability, stiffness, posttraumatic arthritis, and CRPS.

Key Principle

The TFCC is a complex ulnar-sided stabilizing structure of the wrist and distal radioulnar joint.

TFCC tears typically present with:

Ulnar-sided wrist pain, clicking, and pain during forearm rotation or axial loading.

Diagnosis combines:

Focused clinical examination, radiographs, and MRI, while:

Wrist arthroscopy

remains the most definitive diagnostic method.

Stable acute injuries are usually treated with:

Immobilization and rehabilitation.

When surgery is necessary:

Peripheral vascular tears are repaired, whereas:

Central avascular tears are usually debrided.

Associated:

Positive ulnar variance, ulnar impaction, or DRUJ instability

must be recognized and addressed to optimize long-term outcome.

Orthopaedic Surgery - Torticollis

Basics

Torticollis is a condition in which the:

Head and neck are held in an abnormal tilted and rotated position.

The deformity may result from:

Muscular

Skeletal

Neurologic

or other systemic abnormalities.

Typical Posture

The characteristic posture consists of:

Lateral flexion of the head toward one side

with rotation of the:

Chin toward the opposite side.

Classification

Torticollis can broadly be divided into:

Congenital

and

Acquired forms.

Congenital Torticollis

Congenital causes include:

Congenital muscular torticollis

and

Congenital cervical skeletal abnormalities.

Acquired Torticollis

Acquired torticollis may result from:

Trauma

Inflammation

Atlantoaxial rotatory subluxation

Neurologic disease

Ocular disorders

or other:

Systemic conditions.

Synonyms

Historical terms include:

Wry neck

Congenital wry neck

Skeletal wry neck

and

Cock-robin deformity.

Sandifer Syndrome

Sandifer syndrome refers to episodic torticollis or abnormal head positioning associated with:

Gastroesophageal reflux

and sometimes:

Hiatal hernia.

Prevention

Prompt recognition and treatment of the underlying cause may prevent:

Fixed deformity

and reduce the need for:

Surgery.

Epidemiology

Torticollis can occur at:

Any age

depending on the underlying cause.

Congenital Muscular Torticollis

Congenital muscular torticollis usually becomes apparent during the first:

6–8 weeks of life.

Atlantoaxial Rotatory Subluxation

In children, one important acquired cause is:

Atlantoaxial rotatory subluxation.

This may follow:

Upper respiratory infection

Pharyngitis

or

Trauma.

Sex

Males and females are affected approximately:

Equally.

Incidence

Because torticollis has many causes, the exact incidence is difficult to define.

Historical estimates range from approximately:

1 in 100

to

1 in 1,000 individuals.

Risk Factors

Risk factors depend on the specific:

Etiology.

Congenital Muscular Torticollis Risk Factors

Potential associations include:

Difficult delivery

Birth trauma

and localized injury or ischemia involving the:

Sternocleidomastoid muscle.

Atlantoaxial Rotatory Subluxation Risk Factors

Potential triggers include:

Upper respiratory infection

Pharyngitis

and

Neck trauma.

Genetics

Several congenital disorders associated with torticollis have:

Genetic components.

Down Syndrome

Down syndrome is an important genetic condition associated with:

Cervical instability

including abnormalities involving the:

Atlantoaxial joint.

Etiology

The cause depends on whether the disorder is:

Muscular

Skeletal

Neurologic

Inflammatory

or

Traumatic.

Congenital Muscular Torticollis

Congenital muscular torticollis results from shortening and fibrosis of the:

Sternocleidomastoid muscle.

Sternocleidomastoid Effect

Contracture of one sternocleidomastoid causes the head to:

Tilt toward the affected side

while the chin rotates:

Away from the affected side.

Congenital Bony Torticollis

Congenital skeletal causes include abnormalities of the:

Occipitocervical junction

and

Cervical vertebrae.

Bony Abnormalities

Examples include:

Cervical hemivertebrae

Congenital vertebral fusion

and

Asymmetry of the occipital condyles.

Atlantoaxial Rotatory Subluxation

This condition involves abnormal rotation of:

C1 relative to C2.

It may occur after:

Trauma

Inflammation

or occasionally as part of a:

Congenital abnormality.

Diagnosis

Diagnosis begins with careful assessment of:

Head position

Neck motion

Neurologic status

and possible:

Underlying systemic disease.

Signs and Symptoms

The hallmark feature is:

Head tilt with restricted cervical range of motion.

Direction of Motion

The patient may be able to rotate the head farther:

Away from the neutral position

but may have difficulty rotating toward:

Correction.

Neck Mass

Infants with congenital muscular torticollis may have a palpable:

Sternocleidomastoid mass.

This represents localized:

Fibrosis or thickening.

Pain

Pain is less prominent in infants but is more common in:

Older children and adults.

Occipital Symptoms

Some patients report:

Occipital pain

Vertigo

or

Dizziness

that worsens with certain:

Head movements.

Plagiocephaly

Persistent torticollis in infancy may cause secondary:

Plagiocephaly

or facial:

Asymmetry.

Physical Examination

Observe the patient’s:

Head

Face

Neck

and

Shoulder alignment.

Characteristic Position

The ear is typically tilted toward the:

Affected side

while the chin points toward the:

Opposite side.

Range of Motion

Assess:

Active

and

Passive cervical rotation

and

Lateral flexion.

Sternocleidomastoid Examination

Palpate the sternocleidomastoid for:

Tightness

Fibrosis

or a localized:

Mass.

Craniofacial Asymmetry

Longstanding torticollis may produce:

Flattening of the skull

Facial asymmetry

or altered:

Ear position.

Cervical Skeletal Abnormality

A patient with congenital cervical fusion may have a:

Short neck

Low posterior hairline

and reduced:

Cervical motion.

These findings may suggest:

Klippel-Feil syndrome.

Neurologic Examination

A complete neurologic examination should assess:

Strength

Sensation

Reflexes

and

Coordination.

Laboratory Tests

There are no laboratory tests specific for:

Torticollis.

Inflammatory or Neoplastic Evaluation

If infection, inflammatory disease, or malignancy is suspected, laboratory studies may include:

CBC

ESR

and

C-reactive protein.

Additional Specialist Evaluation

When no obvious musculoskeletal cause is present, additional assessment may be needed by:

Ophthalmology

Audiology

or

Gastroenterology.

Imaging

Plain Radiographs

AP and lateral cervical spine radiographs may be used to identify:

Congenital bony abnormalities

Fracture

Dislocation

or abnormal:

Alignment.

CT

CT is particularly useful for evaluating:

Atlantoaxial rotatory subluxation

Occipitocervical injury

Fracture

or

Dislocation.

Rotatory Subluxation

CT may demonstrate persistent abnormal rotational alignment between:

C1

and

C2.

MRI

MRI is indicated when there is concern for:

Spinal cord

Brainstem

Soft-tissue

or other:

Neurologic lesions.

Pathological Findings

In congenital muscular torticollis, the:

Sternocleidomastoid muscle

typically demonstrates:

Fibrosis

and

Shortening.

Differential Diagnosis

The differential diagnosis is broad.

Neurogenic Causes

Potential neurologic causes include:

Brainstem tumor

Cervical spinal cord tumor

Cerebellar tumor

and

Syringomyelia.

Ocular Causes

An ocular disorder may cause compensatory:

Head tilt

to optimize:

Vision.

Traumatic Causes

Traumatic causes include:

Atlantoaxial subluxation

Cervical fracture

and

Occipitocervical dislocation.

Inflammatory Causes

Potential causes include:

Cervical lymphadenitis

and

Rheumatoid arthritis.

Congenital Skeletal Causes

Examples include:

Hemivertebra

Congenital fusion

and

Occipital condyle asymmetry.

Gastrointestinal Cause

In infants, episodic abnormal head positioning may result from:

Sandifer syndrome

associated with:

Gastroesophageal reflux.

Treatment

Treatment depends on the:

Underlying cause

and duration of the:

Deformity.

Congenital Muscular Torticollis

Early treatment consists primarily of:

Stretching exercises.

Early Prognosis

When treatment begins before approximately:

1 year of age

stretching is successful in the vast majority of:

Infants.

Positioning

Parents can position:

Toys

Lights

or other points of interest so the child is encouraged to rotate the head toward the:

Restricted side.

Home Program

A structured home stretching program should focus on:

Gentle cervical rotation

and

Lateral flexion.

Atlantoaxial Rotatory Subluxation

Recent-onset atlantoaxial rotatory subluxation may respond to:

Rest

Analgesics

Physical therapy

and a:

Soft cervical collar.

Early Treatment

Patients treated within approximately the:

First week

often recover without:

Surgery.

Muscle Relaxants

Selected patients may require:

Muscle relaxants

when painful spasm prevents:

Reduction.

Rigid Immobilization

Persistent symptoms may require a:

Hard collar

or another form of:

Cervical bracing.

Traction

If treatment is delayed or the deformity becomes fixed, reduction may require:

Cervical traction.

Activity

Contact sports and strenuous activity should be restricted until the:

Cause is identified

and cervical stability is:

Confirmed.

Physical Therapy

Physical therapy can be curative for many cases of:

Congenital muscular torticollis

and

Recent-onset atlantoaxial rotatory subluxation.

Stretch Direction

The therapist should receive clear instructions regarding:

Direction of stretching

and whether:

Traction

is appropriate.

Medication

Pain may be treated with:

Acetaminophen

or

Ibuprofen

when medically appropriate.

Surgery

Surgery is reserved for selected cases that fail appropriate:

Nonoperative treatment.

Muscular Torticollis Surgery

Persistent congenital muscular torticollis may require:

Sternocleidomastoid release

or

Lengthening.

Timing

Surgery is generally considered when:

Persistent contracture

Restricted motion

or progressive:

Craniofacial asymmetry

remains despite adequate:

Stretching.

Atlantoaxial Rotatory Subluxation Surgery

Severe or chronic atlantoaxial rotatory subluxation that cannot be reduced with:

Traction

may require:

Reduction and C1–C2 fusion.

Congenital Bony Abnormality

Selected congenital cervical abnormalities causing severe persistent deformity or instability may also require:

Spinal fusion.

Follow-Up

Follow-up should assess:

Head position

Range of motion

Neurologic findings

and development of:

Craniofacial asymmetry.

Prognosis

Most cases of torticollis improve:

Spontaneously

or with appropriate:

Treatment.

Early Muscular Torticollis

Congenital muscular torticollis treated early generally has an:

Excellent prognosis.

Delayed Treatment

Delayed treatment increases the risk of:

Persistent contracture

and

Plagiocephaly.

Complications

Potential complications include:

Fixed atlantoaxial subluxation

Persistent neck deformity

and

Plagiocephaly.

Fixed Subluxation

Untreated atlantoaxial rotatory subluxation may become:

Fixed

and increasingly difficult to:

Reduce.

Plagiocephaly

Persistent head positioning in infancy may cause permanent:

Cranial or facial asymmetry

if treatment is delayed beyond the period of active:

Remodeling.

Patient Monitoring

Neurologic status should be followed:

Closely.

Imaging Follow-Up

Bony abnormalities such as persistent:

Atlantoaxial rotatory subluxation

may require repeat:

Imaging.

CT use should be balanced against cumulative:

Radiation exposure, particularly in children.

Clinical Summary

Typical presentation: Head tilted toward one side with the chin rotated to the opposite side and restricted neck motion.

Most common infant cause: Congenital muscular torticollis from sternocleidomastoid fibrosis or contracture.

Important acquired cause in children: Atlantoaxial rotatory subluxation, often after trauma or an upper respiratory infection.

Key examination: Assess cervical ROM, palpate the sternocleidomastoid, look for plagiocephaly, and perform a complete neurologic examination.

Imaging: Plain cervical radiographs for bony abnormalities; CT for suspected C1–C2 rotatory subluxation or fracture; MRI for suspected spinal cord, brainstem, or other neurologic disease.

Initial treatment: Early muscular torticollis responds to stretching and positioning; recent atlantoaxial rotatory subluxation may respond to analgesics, therapy, and cervical immobilization.

Surgery: Reserved for persistent muscular contracture or irreducible/fixed atlantoaxial abnormalities.

Red flags: New neurologic deficits, severe pain, trauma, fever, progressive deformity, or acquired torticollis without an obvious benign explanation.

Key Principle

Torticollis is a clinical posture characterized by lateral head tilt with rotation of the chin in the opposite direction.

It may arise from:

Muscular, skeletal, neurologic, inflammatory, traumatic, ocular, or gastrointestinal causes.

In infants, the most common form is:

Congenital muscular torticollis, which usually responds well to early:

Stretching and positioning.

In older children with acute painful torticollis, especially after:

Trauma or upper respiratory infection, consider:

Atlantoaxial rotatory subluxation.

Persistent, painful, neurologically abnormal, or atypical torticollis requires evaluation for an underlying:

Structural or neurologic cause.

Orthopaedic Surgery - Toe Walking

Basics

Toe walking describes a gait pattern in which a child walks predominantly on the:

Forefoot

with limited or absent:

Heel strike.

Idiopathic toe walking is relatively common in:

Toddlers and young children.

Idiopathic Toe Walking

Many children who toe walk have no identifiable:

Neurologic

Orthopaedic

or

Neuromuscular disorder.

When other causes have been excluded, the condition is termed:

Idiopathic toe walking.

Achilles Tendon Tightness

Some children develop or have an associated shortened:

Achilles tendon

or tight:

Gastrocnemius-soleus complex.

This may restrict:

Ankle dorsiflexion

and reinforce the toe-walking pattern.

Natural History

Some children spontaneously develop a normal:

Heel-toe gait

as they:

Grow.

Persistent Toe Walking

Persistent, nearly exclusive toe walking beyond approximately:

5 years of age

should prompt careful assessment for an underlying:

Neurologic or neuromuscular disorder.

Epidemiology

Toe walking is usually first noticed when the child begins:

Independent walking.

Incidence

Transient toe walking is:

Common

during early childhood.

Sex

Boys and girls are affected approximately:

Equally.

Risk Factors

Potential associations include:

Positive family history

Premature birth

Low Apgar score

and other:

Neuromotor abnormalities.

Genetics

A familial tendency is relatively common.

Historical studies have reported a positive family history in up to approximately:

50% of patients.

Etiology

Idiopathic toe walking is thought to involve a combination of:

Neuromotor patterning

and, in some children,

Achilles tendon shortening.

Diagnosis

Idiopathic toe walking is primarily a:

Clinical diagnosis.

Importantly, it is a:

Diagnosis of exclusion.

A neurologic, neuromuscular, or structural cause should be excluded before labeling the gait:

Idiopathic.

History

The clinician should establish:

When toe walking began

Whether it has always been present

and whether the child can voluntarily walk with:

Heel strike.

Developmental History

Ask about:

Birth history

Prematurity

Developmental milestones

and any history of:

Motor delay.

Family History

Ask whether parents or siblings had:

Toe walking

Neuromuscular disease

or abnormal:

Gait development.

New-Onset Toe Walking

Toe walking that begins after a period of normal:

Heel-toe gait

is more concerning than toe walking present from the onset of:

Walking.

This pattern warrants evaluation for an acquired:

Neurologic

Spinal

or

Musculoskeletal cause.

Physical Examination

The child should ideally be examined wearing:

Shorts

with the lower extremities fully visible.

Gait Observation

Observe the feet throughout:

Standing

Walking

and, when possible,

Running.

Heel Strike

Determine whether the child demonstrates:

Heel strike

at any point during the gait cycle.

Voluntary Correction

Ask the child to attempt:

Heel-toe walking.

The ability to correct the gait voluntarily may support a diagnosis of:

Idiopathic toe walking.

Neurologic Examination

A complete neurologic examination should assess for:

Spasticity

Weakness

Hyperreflexia

Abnormal tone

and other signs of:

Neuromuscular disease.

Ankle Range of Motion

Measure ankle:

Dorsiflexion

with the knee:

Flexed

and

Extended.

Silfverskiöld Principle

Comparing ankle dorsiflexion with the knee flexed and extended helps distinguish:

Gastrocnemius tightness

from combined:

Gastrocnemius-soleus contracture.

Calf Examination

Palpate and inspect the calf for:

Atrophy

Abnormal masses

or

Pseudohypertrophy.

Pseudohypertrophy

Prominent calf enlargement can be a clue to conditions such as:

Muscular dystrophy.

Hamstrings and Adductors

Examine the:

Hamstrings

and

Hip adductors

for abnormal:

Tightness.

This may suggest an underlying:

Neurologic disorder.

Passive and Active Motion

Document both:

Passive

and

Active ankle range of motion.

Testing

Additional investigations are usually unnecessary when the history and physical examination are entirely consistent with:

Idiopathic toe walking.

Neuromuscular Testing

When muscular dystrophy or another myopathic process is suspected, testing may include:

Creatine kinase

and selected:

Genetic studies.

Muscle biopsy is now reserved for selected cases when the diagnosis remains:

Uncertain.

Imaging

MRI of the spine may be appropriate when examination suggests:

Spinal cord pathology

Tethered cord

or another cause of:

Spasticity.

Differential Diagnosis

Important conditions to exclude include:

Cerebral palsy

Muscular dystrophy

Tethered cord syndrome

Hereditary spastic paraplegia

Charcot-Marie-Tooth disease

and

Arthrogryposis.

Cerebral Palsy

Toe walking from cerebral palsy is often accompanied by:

Spasticity

Hyperreflexia

and other abnormalities of:

Motor control.

Muscular Dystrophy

Muscular dystrophy may produce:

Proximal weakness

Gower sign

and

Calf pseudohypertrophy.

Tethered Cord

Tethered cord or other spinal pathology may present with:

New gait abnormality

Weakness

Spasticity

or abnormalities of:

Bladder or bowel function.

Charcot-Marie-Tooth Disease

Charcot-Marie-Tooth disease may cause:

Distal weakness

Pes cavus

and altered:

Gait mechanics.

Treatment

Treatment depends on:

Age

Severity

Ankle range of motion

and whether the child can voluntarily achieve:

Heel-toe gait.

General Measures

Initial management usually consists of:

Observation

Stretching

and

Encouragement of normal heel-toe walking.

Mild Cases

Young children with:

Flexible ankles

and no underlying disorder may simply be:

Observed.

Stretching

Regular stretching of the:

Gastrocnemius-soleus complex

may help preserve or improve:

Ankle dorsiflexion.

Orthotics

Orthotic devices may help guide gait in selected children but, when used alone, do not reliably correct persistent:

Toe walking.

Serial Casting

Serial casting may be used when ankle dorsiflexion is:

Restricted.

Casting Technique

The ankle is gradually positioned into increasing:

Dorsiflexion.

The goal is often to achieve at least approximately:

10° of dorsiflexion

while facilitating development of a:

Heel-toe gait.

Cast Changes

Casts are typically changed approximately:

Weekly

until the desired:

Range of motion

is obtained.

Night Bracing

Night splints holding the ankle in:

Dorsiflexion

may help preserve gains achieved through:

Casting

or

Surgery.

Physical Therapy

Physical therapy may be helpful in children with:

Mild or flexible toe walking.

Range-of-Motion Exercises

Therapy may include:

Passive ankle stretching

and

Active dorsiflexion exercises.

Gait Training

Children who can dorsiflex beyond neutral may practice:

Heel walking

and

Heel-toe gait.

This can reinforce a more typical:

Motor pattern.

Strengthening

Therapy may also focus on strengthening the:

Ankle dorsiflexors

and improving:

Balance and gait control.

Surgery

Surgery is considered when conservative measures fail and persistent:

Achilles contracture

prevents normal:

Heel strike.

Achilles Lengthening

The principal operative procedure is:

Achilles tendon lengthening.

Techniques

Lengthening may be performed using:

Percutaneous

or

Open techniques.

A:

Z-lengthening

is one traditional approach.

Timing

Surgery is generally considered when a child has persistent toe walking approaching the:

School-age years

and fails to develop a functional:

Heel-toe gait.

Goal of Surgery

The objective is to restore sufficient:

Ankle dorsiflexion

to permit normal:

Heel contact during gait.

Avoiding Overlengthening

Excessive Achilles lengthening must be avoided because it may produce:

Weak plantarflexion

and a:

Calcaneal or crouched gait.

Referral

Referral to a pediatric orthopaedic specialist is appropriate when:

Toe walking begins after previously normal gait

or when the child fails to improve by:

Kindergarten or early school age.

Neurologic Referral

Neurology or other specialist evaluation may be required when examination suggests:

Spasticity

Weakness

Developmental delay

or another:

Neuromuscular disorder.

Follow-Up

Children should be reassessed for changes in:

Gait pattern

Ankle dorsiflexion

and

Achilles tendon flexibility.

Prognosis

Many children with idiopathic toe walking spontaneously develop a normal:

Heel-toe gait.

Early Resolution

A substantial number improve by approximately:

3 years of age.

Persistent Toe Walking

Persistent toe walking into adolescence or adulthood may result in:

Metatarsal calluses

Achilles contracture

and impaired:

Balance.

Complications

Important complications include:

Failure to recognize an underlying neurologic disorder

Recurrence after treatment

and complications of:

Achilles lengthening.

Missed Neurologic Diagnosis

The most important diagnostic complication is incorrectly labeling pathologic toe walking as:

Idiopathic.

Recurrence

Toe walking may recur after:

Casting

or

Surgery

particularly if the underlying gait pattern persists.

Achilles Overlengthening

Excessive surgical lengthening can produce:

Plantarflexion weakness

and abnormal:

Calcaneal or crouch gait.

Patient Monitoring

Follow-up should document:

Heel strike

Ankle dorsiflexion

Gait symmetry

Muscle strength

and any emerging:

Neurologic findings.

Clinical Summary

Typical patient: Toddler who has walked on the toes since beginning independent ambulation but otherwise has normal development and neurologic examination.

Key diagnostic principle: Idiopathic toe walking is a diagnosis of exclusion; cerebral palsy, muscular dystrophy, tethered cord, hereditary spastic disorders, and peripheral neuropathy must be considered.

Key examination: Observe gait and measure ankle dorsiflexion with the knee both flexed and extended while performing a complete neurologic examination.

Testing: Usually unnecessary unless the examination suggests a neurologic, spinal, or myopathic disorder.

Natural history: Many children improve spontaneously, particularly by about 3 years of age.

Initial treatment: Observation, Achilles stretching, gait training, and selected physical therapy.

Persistent contracture: Serial casting and night bracing may improve ankle dorsiflexion.

Surgery: Achilles lengthening is reserved for persistent toe walking with fixed equinus that fails conservative management.

Red flag: New-onset toe walking after a previously normal heel-toe gait warrants further investigation.

Key Principle

Idiopathic toe walking is a common childhood gait pattern characterized by forefoot walking without an identifiable neurologic or orthopaedic cause.

It is a:

Diagnosis of exclusion.

Persistent toe walking beyond approximately:

5 years of age, new-onset toe walking, weakness, spasticity, abnormal reflexes, or developmental abnormalities should prompt evaluation for:

Neuromuscular or spinal disease.

Children with flexible ankles often improve with:

Observation, stretching, and gait retraining.

Persistent equinus may be treated with:

Serial casting and night bracing, while:

Achilles tendon lengthening

is reserved for selected children with fixed contracture and persistent functional toe walking.

Orthopaedic Surgery - Tibial Torsion

Basics

Tibial torsion describes rotational alignment of the:

Tibia

together with the:

Ankle and foot

either internally or externally around the longitudinal axis of the leg.

Some degree of tibial rotation is part of:

Normal development.

The condition becomes clinically abnormal when rotation is markedly outside the normal range for:

Age.

Definition of Abnormality

Abnormal torsion is often defined as rotational alignment greater than approximately:

Two standard deviations from the age-adjusted mean.

Classification

Tibial torsion may be classified as:

Internal tibial torsion

External tibial torsion

or

Neuromuscular tibial torsion.

Internal Tibial Torsion

Internal tibial torsion produces:

In-toeing

with the foot directed inward relative to the:

Knee.

External Tibial Torsion

External tibial torsion produces:

Out-toeing

with the foot directed outward relative to the:

Knee.

Neuromuscular Torsion

Abnormal tibial rotation may occur with neuromuscular conditions such as:

Cerebral palsy

or

Spina bifida.

Synonyms

Internal tibial torsion may be referred to as:

In-toeing

or historically:

Pigeon-toeing.

External tibial torsion produces:

Out-toeing.

Epidemiology

Abnormal tibial rotation is a common reason for:

Pediatric orthopaedic evaluation.

Age

Internal tibial torsion is most commonly noticed after the child begins:

Walking

and is especially frequent in children younger than approximately:

3 years.

Normal Development

Younger children normally have relatively greater:

Internal tibial rotation.

With growth, the tibia progressively rotates:

Externally.

Sex

No important consistent difference has been demonstrated between:

Boys and girls.

Persistence

Persistent clinically significant torsion occurs in fewer than approximately:

1–2% of children.

Genetics

Internal tibial torsion is believed to reflect a combination of:

Genetic influences

and

Intrauterine positioning.

Family History

A family history of persistent abnormal torsion may influence the likelihood of:

Spontaneous correction.

Etiology

Most idiopathic internal tibial torsion appears to result from normal developmental variation influenced by:

Genetics

and

Fetal position.

Associated Conditions

In infants, internal tibial torsion may coexist with:

Metatarsus adductus

or

Developmental genu varum.

Diagnosis

Diagnosis is primarily:

Clinical.

A careful rotational profile should assess the child from:

Hip to foot.

Signs and Symptoms

Parents commonly become concerned because the child’s walking pattern looks different from that of:

Siblings or peers.

Cosmetic Concern

The principal concern is usually:

Appearance during walking or running.

Tripping

Parents may report:

Frequent tripping

or

Falling.

In young children, however, some of this may simply reflect:

Normal motor development.

Pain

Pain is:

Unusual.

A painful gait suggests that another diagnosis should be:

Considered.

Apparent Limp

Parents may describe a limp, but uncomplicated tibial torsion usually does not produce a true:

Painful limp.

Physical Examination

Examination begins with observation of:

Standing

and

Walking.

Gait

If the child is ambulatory, observe for:

Heel-toe progression

In-toeing

Out-toeing

and

Limp.

Neurologic Warning Sign

Absence of a normal:

Heel-toe gait

may be an early clue to an underlying:

Neuromuscular disorder

such as:

Cerebral palsy.

Foot Progression Angle

The:

Foot progression angle

is the angle between the long axis of the foot and the direction in which the child is:

Walking.

Normal Foot Progression

The normal angle is usually slightly:

External

but there is a broad normal range extending approximately:

15° internally to 15° externally.

Supine Examination

Before focusing on torsion, examine the hips for:

Stability

and

Abduction.

Prone Examination

The child is then placed:

Prone

to evaluate:

Hip rotation

and

Tibial torsion.

The pelvis must remain:

Level and stationary

for accurate measurement.

Femoral Anteversion

Femoral anteversion can be estimated by determining the hip position in which the:

Greater trochanter

is most prominent laterally.

Tibial Torsion Measurement

Tibial torsion is commonly estimated using the:

Thigh-foot angle

or

Transmalleolar axis.

Thigh-Foot Angle

With the child prone and the knee flexed approximately 90°, compare the long axis of the:

Thigh

with the long axis of the:

Foot.

Internal deviation suggests:

Internal tibial torsion.

Bimalleolar Axis

The relationship between the:

Medial malleolus

Lateral malleolus

and the proximal tibia can also estimate:

Tibial rotation.

Foot Examination

The shape of the foot should be assessed carefully because:

Metatarsus adductus

may itself be responsible for:

In-toeing.

Imaging

Imaging is usually:

Not required.

The clinical rotational profile generally provides sufficient information for:

Management.

Pelvic Radiograph

An AP pelvis radiograph is appropriate when there is:

Asymmetric hip abduction

or markedly restricted:

Hip abduction.

In a toddler, abduction below approximately:

60°

raises concern for:

Developmental hip dysplasia.

Foot Radiographs

Foot radiographs may help evaluate suspected:

Metatarsus adductus

when clinical findings are unclear.

Long-Leg Radiographs

Full-length lower-extremity radiographs may be useful when there is associated:

Genu varum

or another:

Angular deformity.

CT

CT can measure tibial rotation accurately but is usually:

Unnecessary

because most childhood torsional abnormalities can be evaluated:

Clinically.

Differential Diagnosis

Important alternatives include:

Blount disease

Excessive femoral anteversion

Metatarsus adductus

Cerebral palsy

and

Developmental dysplasia of the hip.

Blount Disease

Blount disease may combine:

Pathologic genu varum

with

Internal tibial torsion.

Unlike physiologic torsion, it represents a progressive:

Growth disorder.

Femoral Anteversion

Persistent in-toeing in an older child may result from increased:

Femoral anteversion

rather than ongoing tibial torsion.

Treatment

Most cases require:

Observation and reassurance.

General Measures

Internal tibial torsion is the most common cause of in-toeing in children younger than approximately:

3 years.

Natural History

With growth, the tibia normally rotates externally so that by later childhood the:

Lateral malleolus

lies approximately:

20–30° posterior

to the:

Medial malleolus.

Spontaneous Improvement

Almost all children with idiopathic internal tibial torsion demonstrate substantial improvement by approximately:

3–5 years of age.

Parental Education

The most important intervention is often:

Explanation of the natural history.

Parents should understand that most cases improve through:

Normal growth and development.

Braces and Orthotics

Devices such as:

Night splints

Denis Browne bars

Shoe wedges

Special shoes

or

Orthotics

have not been shown to alter the natural rotational development of the:

Tibia.

External Tibial Torsion

Marked external torsion is less likely to correct spontaneously, particularly when it is:

Asymmetric.

Selected persistent cases may eventually require:

Derotational osteotomy.

Persistent In-Toeing

If in-toeing persists or becomes more obvious after approximately:

3–4 years

the cause may increasingly be:

Femoral anteversion

rather than tibial torsion.

Activity

No routine activity restriction is:

Required.

Children may participate normally in:

Play

Sports

and

Physical education.

Physical Therapy

Formal physical therapy generally does not correct:

Bony tibial rotation.

Reason Therapy Is Limited

The natural change occurs over:

Years

rather than over the shorter time frame expected from:

Therapy.

Recreational Activities

Some clinicians encourage activities requiring awareness of foot position, such as:

Ice skating

Roller skating

Track

or

Ballet.

There is little evidence that these activities directly change:

Tibial torsion.

Surgery

The only operation used to correct persistent severe tibial torsion is:

Derotational tibial osteotomy.

Timing of Surgery

Surgery is rarely considered before approximately:

8–10 years of age.

Indications

Surgery may be considered when there is:

Persistent severe rotational deformity

Functional difficulty

or major:

Cosmetic concern

after the age at which spontaneous improvement is expected.

Rotational Thresholds

Historical guidelines suggest considering osteotomy when the:

Thigh-foot angle remains internally rotated by approximately 20° or more

or when external tibial torsion measures approximately:

35° or more.

These values should be interpreted together with:

Symptoms

Function

and

Age.

Neuromuscular Patients

Children with:

Cerebral palsy

have a greater risk of recurrent torsion after:

Early surgery.

Osteotomy Level

Derotational osteotomy is often performed near the:

Distal tibial metaphysis

while avoiding injury to the:

Growth plate.

Postoperative Immobilization

The leg is commonly immobilized in a cast for approximately:

6–8 weeks.

Follow-Up

Observation may be performed:

Annually

or

Every 1–2 years

when parents desire documentation of:

Rotational improvement.

Prognosis

Tibial torsion is usually:

Self-limiting

and represents part of normal:

Childhood development.

Family Alignment

If the parents and older siblings demonstrate normal rotational alignment, spontaneous correction in the child is:

Highly likely.

Familial Persistence

A strong family history of persistent tibial torsion may slightly reduce the probability of:

Complete spontaneous correction.

Arthritis Risk

Isolated idiopathic tibial torsion in childhood has not been shown to produce a significant increased risk of:

Hip

Knee

or

Spinal arthritis.

Complications

Complications are primarily related to:

Surgical treatment.

Surgical Complications

Potential complications include:

Physeal injury

Neurovascular injury

Nonunion

Malunion

and

Implant-related problems.

Patient Monitoring

Follow-up should document:

Foot progression angle

Thigh-foot angle

Hip rotation

and overall:

Gait.

Patient Teaching

Parental education is central to management.

Most children improve naturally without:

Braces

Special shoes

or

Surgery.

Showing families how rotational alignment normally changes with age may provide useful:

Reassurance.

Frequently Asked Questions

When should my child’s tibial torsion improve?

Most children progressively improve during early childhood. Continued observation is appropriate as long as improvement is occurring. Persistent severe deformity after approximately:

8–10 years of age

may justify consideration of surgery if it is functionally or cosmetically important.

Does tibial torsion cause arthritis later in life?

Isolated developmental tibial torsion has not been convincingly shown to increase the risk of:

Hip, knee, or back arthritis.

Clinical Summary

Typical patient: Toddler with painless in-toeing noticed after beginning to walk.

Key examination: Observe gait and measure the foot progression angle and thigh-foot angle while also assessing hip rotation and foot shape.

Most important differential: Femoral anteversion, metatarsus adductus, Blount disease, hip dysplasia, and neurologic disease.

Imaging: Usually unnecessary unless the examination suggests another abnormality.

Natural history: Internal tibial torsion usually improves substantially by 3–5 years of age.

Treatment: Observation and parental reassurance; braces, special shoes, and orthotics do not alter tibial rotation.

Surgery: Rarely required and generally reserved for persistent severe deformity after about 8–10 years of age.

Key Principle

Tibial torsion is usually a developmental rotational variation of the tibia, most often presenting as:

In-toeing in toddlers.

Diagnosis is primarily:

Clinical, using gait observation and measurement of the:

Foot progression and thigh-foot angles.

Most internal tibial torsion resolves spontaneously with:

Growth, and treatment consists primarily of:

Observation and reassurance.

Bracing and special footwear have not been shown to accelerate:

Correction.

Derotational osteotomy is reserved for rare cases of:

Persistent severe symptomatic torsion in older children.

Orthopaedic Surgery - Tibial Spine Fracture

Basics

A tibial spine fracture is an avulsion fracture involving the:

Intercondylar eminence of the proximal tibia.

It is also referred to as a:

Tibial eminence fracture.

Anatomy

The:

Anterior tibial spine

provides an important attachment site for the:

Anterior cruciate ligament.

Pediatric Mechanism

In the skeletally immature knee, the ACL may be stronger than the incompletely ossified:

Tibial spine.

Therefore, traumatic force may produce:

Bony avulsion of the tibial spine

rather than a midsubstance:

ACL tear.

ACL Injury in Children

Although tibial spine avulsion is characteristic of the immature knee, children can still sustain:

Midsubstance ACL tears.

Femoral Notch Anatomy

A relatively narrow:

Femoral intercondylar notch

may predispose some children toward:

Midsubstance ACL injury

rather than:

Tibial spine avulsion.

Classification

The classic:

Meyers and McKeever classification

is based primarily on the degree of:

Fracture displacement.

Type I

Type I is:

Minimally displaced or essentially nondisplaced.

The fragment remains near its normal:

Anatomic position.

Type II

Type II is a:

Hinged fracture.

The anterior portion of the fragment is elevated while the posterior portion remains attached, creating an intact:

Posterior hinge.

Type III

Type III demonstrates:

Complete separation of the fragment

with:

Upward displacement

and often:

Rotation.

Epidemiology

Tibial spine fractures are considerably more common in:

Children

than in adults.

Incidence

Historical data suggest that these fractures occur approximately:

Four times more often in children than adults.

Etiology

The injury usually results from forces that tension the:

ACL.

Common Mechanisms

Mechanisms include:

Twisting injury

Varus-valgus stress

and

Hyperextension.

Typical Causes

Common causes include:

Bicycle falls

Athletic injuries

and

Motor vehicle collisions.

Diagnosis

Diagnosis is based on:

Traumatic history

Physical examination

and

Imaging.

Signs and Symptoms

Patients usually report:

Knee pain

after trauma.

Weight Bearing

The patient often refuses or is unable to:

Bear weight.

Swelling and Hemarthrosis

Typical findings include:

Knee swelling

Effusion

and

Hemarthrosis.

Loss of Extension

The patient may lack full:

Knee extension

because the elevated fracture fragment creates a:

Mechanical block.

Physical Examination

The knee should be examined for:

Tenderness

Effusion

Range of motion

and

Stability.

Stability Testing

Gently assess:

Anterior

Posterior

Varus

and

Valgus stability.

In the acute setting, reliable testing may be difficult because of:

Pain

and

Guarding.

Anterior Laxity

Some patients demonstrate increased:

Anterior tibial translation

because the ACL remains attached to the:

Avulsed fragment.

Hemarthrosis

A tense hemarthrosis may significantly increase:

Pain

and limit the examination.

Imaging

Plain Radiographs

Standard:

AP

and

Lateral knee radiographs

are usually sufficient to identify the injury.

Importance of the Lateral View

The fracture is often best appreciated on the:

Lateral radiograph.

The degree of displacement seen on this view forms the basis of the:

Meyers and McKeever classification.

Small Fragments

The avulsed fragment may occasionally be:

Quite small

and can be subtle on:

Plain radiographs.

Additional Views

A:

Tunnel view

or an image oriented parallel to the slope of the:

Tibial plateau

may improve visualization.

MRI

MRI is useful for evaluating associated:

Meniscal

Ligamentous

and

Chondral injuries.

Adults

Adults with tibial spine fractures have a higher incidence of associated:

Meniscal tears

and other injuries that may require:

Operative treatment.

MRI is therefore particularly useful in:

Adult patients.

Pediatric MRI

MRI may also be helpful in children when there is concern for:

Meniscal entrapment

ACL injury

or unexplained failure of:

Closed reduction.

Pathological Findings

The fundamental injury is an:

Avulsion at the tibial attachment of the ACL.

ACL Footprint

The ACL has a broad tibial attachment and may blend with structures around the:

Anterior intercondylar region.

Meniscal Interposition

The:

Anterior horn of the medial meniscus

or other soft tissue may become trapped in the:

Fracture site.

This can prevent successful:

Reduction.

Differential Diagnosis

Important alternatives or associated injuries include:

Isolated ACL injury

PCL injury

MCL injury

LCL injury

Patellar fracture

Patellar tendon rupture

Tibial tubercle fracture

Tibial plateau fracture

and

Meniscal injury.

Treatment

Treatment depends primarily on:

Fracture displacement

Reducibility

Associated injuries

and

Skeletal maturity.

Initial Measures

Initial treatment includes:

Ice

Elevation

and

Immobilization.

Painful Hemarthrosis

If a large hemarthrosis is producing severe pain, aspiration may provide:

Symptomatic relief

and facilitate:

Examination.

Type I Fractures

Type I injuries are usually treated:

Nonoperatively.

Type II Fractures

Type II fractures may also be treated nonoperatively if they can be:

Completely reduced

and remain:

Stable.

Closed Reduction

Reduction is usually attempted by bringing the knee into:

Extension

or slight:

Hyperextension.

This can help restore the avulsed fragment toward its:

Anatomic position.

Immobilization Position

After successful closed reduction, the knee is generally immobilized near:

Full extension

typically around:

0–10° of flexion.

Immobilization Duration

Traditional immobilization is approximately:

6 weeks.

Modern treatment aims to balance fracture healing with avoidance of excessive:

Knee stiffness.

Type III Fractures

Type III fractures usually require:

Operative reduction and fixation.

Reason for Surgery

Surgery helps restore:

Articular anatomy

ACL tension

and

Knee stability.

Irreducible Type II Injury

A Type II fracture that cannot be reduced because of:

Soft-tissue interposition

should also be considered for:

Operative treatment.

Weight Bearing

Selected patients may be allowed:

Protected weight bearing

with the knee immobilized in:

Extension.

Exact weight-bearing status depends on:

Fracture stability

and

Treatment method.

Physical Therapy

Rehabilitation begins after adequate fracture:

Healing and stability.

Range of Motion

Therapy focuses on restoring:

Full knee extension

and progressive:

Flexion.

Strengthening

Progressive strengthening emphasizes the:

Quadriceps

and other muscles supporting:

Knee function.

Medication

Pain after injury may be treated with:

Acetaminophen

NSAIDs when appropriate

or other short-term:

Analgesics.

Surgery

Operative treatment is indicated for fractures that remain:

Displaced

or

Unreduced.

Arthroscopic Treatment

Arthroscopic reduction and fixation has become the preferred approach for many:

Displaced tibial spine fractures.

Advantages of Arthroscopy

Arthroscopy allows:

Direct visualization of the fracture

Removal of interposed tissue

and assessment of associated:

Meniscal or chondral injury.

Open Surgery

Open reduction remains an option when:

Arthroscopic reduction is not possible

or the fracture pattern requires:

Direct exposure.

Reduction

The fragment should be restored to its normal:

Anatomic position.

Any interposed:

Meniscus

Intermeniscal ligament

or other:

Soft tissue

must be removed from the fracture site.

Fixation

Fixation may be achieved using:

Screws

or

Heavy sutures.

Screw Fixation

Screw fixation can provide strong compression when the fragment is:

Large enough.

Suture Fixation

Suture fixation is particularly useful for:

Small

Comminuted

or

Cartilaginous fragments.

Physeal Considerations

In skeletally immature patients, implants should avoid crossing the:

Proximal tibial physis

whenever possible.

Near Skeletal Maturity

Crossing the physis may be acceptable in selected patients who are:

Close to skeletal maturity.

Postoperative Care

Postoperative management commonly includes a period of:

Protected motion

and

Bracing.

Early Motion

Because postoperative stiffness is an important complication, controlled:

Range-of-motion exercises

are generally begun once fixation permits.

Referral

Tibial spine fractures should be evaluated by an:

Orthopaedic surgeon.

Follow-Up

Patients should be followed closely to ensure:

Maintenance of reduction

and

Fracture healing.

Radiographic Follow-Up

Serial radiographs help assess:

Fragment position

and progression toward:

Union.

After Healing

Once the fracture has healed, the knee should be examined for residual:

ACL laxity

and

Functional instability.

Prognosis

When the fragment is anatomically reduced and securely fixed, functional results are generally:

Excellent.

ACL Stability

Most patients recover satisfactory:

ACL function

after successful healing.

Residual Laxity

Some patients retain measurable:

Anterior laxity

despite fracture union.

This may be asymptomatic.

Symptomatic Instability

Persistent symptomatic instability may eventually require:

ACL reconstruction.

Complications

Potential complications include:

Loose bodies

ACL laxity

Knee stiffness

Postoperative infection

and

Venous thromboembolism.

Knee Stiffness

Loss of motion is one of the most important complications, particularly when immobilization is:

Prolonged.

Arthrofibrosis

Severe postoperative stiffness may develop from:

Arthrofibrosis.

Prevention emphasizes:

Stable fixation

and appropriately timed:

Early motion.

ACL Laxity

Residual ACL laxity may result from:

Ligament stretching

Imperfect reduction

or altered:

Ligament tension.

Loose Body

A displaced osseous or osteochondral fragment may remain within the:

Joint

and become a:

Loose body.

Infection

Postoperative infection is uncommon but may involve:

Superficial tissues

or the:

Knee joint.

DVT

Venous thromboembolism is uncommon in children but remains a potential complication, particularly in:

Older or higher-risk patients.

Patient Monitoring

Monitoring should include assessment of:

Pain

Range of motion

Fracture alignment

Knee stability

and

Strength.

Key Principle

A tibial spine fracture is an avulsion fracture of the ACL attachment at the tibial intercondylar eminence, occurring most commonly in the:

Skeletally immature knee.

The classic:

Meyers and McKeever classification

describes Type I minimally displaced, Type II hinged, and Type III completely displaced fractures.

Plain:

AP and lateral knee radiographs

usually establish the diagnosis, while MRI is useful for identifying associated:

Meniscal and ligamentous injuries.

Nondisplaced or successfully reduced Type I and selected Type II injuries may be managed with:

Immobilization, whereas displaced, irreducible, or unstable fractures generally require:

Arthroscopic or open reduction and internal fixation.

The major long-term concerns are:

Knee stiffness, residual ACL laxity, and symptomatic instability.

Orthopaedic Surgery - Tibial Shaft Fracture

Basics

A tibial shaft fracture is a fracture involving the:

Diaphysis of the tibia.

It is one of the most common major:

Orthopaedic fractures.

Anatomic Definition

The tibial shaft generally refers to the portion of the tibia extending from approximately:

5 cm distal to the knee joint

to approximately:

5 cm proximal to the ankle joint.

Fractures outside this region are more appropriately classified as:

Proximal tibial

or

Distal tibial fractures.

Clinical Importance

The tibia has relatively limited soft-tissue coverage, particularly along its:

Anteromedial surface.

As a result, tibial shaft fractures have an important association with:

Open injury

Soft-tissue compromise

Compartment syndrome

and

Delayed or nonunion.

Epidemiology

Tibial shaft fractures occur across all age groups but are particularly common in:

Young adults.

Sex

Historically, the highest incidence has been reported among:

Young adult males

because of greater exposure to:

High-energy trauma.

Prevalence

Tibial shaft fracture has historically been described as one of the most common long-bone fractures in:

Young adult men.

Risk Factors

Common mechanisms include:

Motor vehicle collisions

Pedestrian-versus-vehicle trauma

Falls from height

and

Skiing injuries.

Etiology

A substantial amount of energy is usually required to fracture the:

Tibial diaphysis.

The fracture pattern partly reflects:

Magnitude

Direction

and

Rate of application of force.

Rapidly Applied Force

A sudden high-energy force may produce a relatively simple:

Transverse fracture.

Rotational or Slower Energy Transfer

When energy is transmitted through the bone over a longer period or with a rotational component, the fracture may become:

Spiral

Oblique

or

Comminuted.

Associated Conditions

Important associated injuries include:

Compartment syndrome

Fibular fracture

and, less commonly,

Peripheral nerve injury.

Fibular Fracture

An associated fibular fracture is common.

Most fibular fractures do not require separate treatment unless they influence:

Alignment

Ankle stability

or

Surgical strategy.

Compartment Syndrome

Tibial shaft fractures are among the injuries most strongly associated with:

Acute compartment syndrome.

Bleeding and muscle edema may increase pressure within the:

Leg compartments

and compromise:

Muscle and nerve perfusion.

Neural Injury

Major nerve injury is relatively:

Uncommon

but the neurologic examination must be documented carefully.

Diagnosis

Diagnosis is usually straightforward because the injury often produces:

Severe pain

Deformity

and inability to:

Bear weight.

Signs and Symptoms

Patients commonly report:

Severe leg pain

Swelling

and

Inability to walk.

Functional Loss

Most displaced fractures prevent:

Weight bearing

and make movement of the injured leg:

Extremely painful.

Physical Examination

The examination should focus on:

Skin integrity

Alignment

Neurovascular function

and signs of:

Compartment syndrome.

Skin Examination

Carefully inspect the entire leg for:

Lacerations

Puncture wounds

Abrasions

and

Skin tenting.

Open Fracture

Any wound that communicates with the fracture makes the injury an:

Open fracture.

A small skin opening may communicate with a much larger:

Underlying injury.

Deformity

Document:

Angulation

Rotation

Shortening

and gross:

Translation.

Rotational Alignment

Rotational deformity should be compared with the:

Contralateral leg

when possible.

Neurologic Examination

Document motor and sensory function of the major nerves of the:

Lower leg and foot.

Common Peroneal Nerve

Assess:

Ankle dorsiflexion

and

Great-toe extension.

These functions primarily evaluate the:

Deep peroneal nerve.

Tibial Nerve

Assess:

Ankle plantarflexion

and

Toe plantarflexion.

Sensory Testing

Sensation should be examined over the distributions of the:

Superficial peroneal

Deep peroneal

Tibial

Sural

and

Saphenous nerves.

Vascular Examination

Document:

Dorsalis pedis pulse

Posterior tibial pulse

Capillary refill

Skin temperature

and

Foot color.

Compartment Syndrome Assessment

Every patient with a tibial shaft fracture should be repeatedly evaluated for:

Acute compartment syndrome.

Incidence

Historical series have reported compartment syndrome in approximately:

10% of tibial shaft fractures

although the risk varies according to:

Mechanism and fracture pattern.

Most Important Symptom

A key warning feature is:

Pain out of proportion to the apparent injury.

However, because displaced tibial fractures are intrinsically painful, the more concerning finding is pain that is:

Progressively worsening

or unexpectedly severe despite:

Appropriate analgesia and stabilization.

Pain With Passive Stretch

An early and important finding is:

Pain with passive stretch of muscles within the affected compartment.

Toe Motion

Passive movement of the toes may reproduce compartment pain.

For example, passive:

Toe extension

stretches the deep posterior flexor musculature, while passive:

Toe flexion

stretches the anterior compartment extensors.

Important Limitation

Pain with ankle motion may be difficult to interpret because a displaced tibial fracture itself can cause substantial:

Pain.

Serial examination is therefore essential.

Late Findings

Late findings may include:

Sensory loss

Motor weakness

and eventually:

Absent pulses.

Pulse loss is a very late sign and should never be awaited before treatment.

Imaging

Plain Radiographs

Plain radiographs are usually sufficient to establish the diagnosis.

Required Views

Obtain:

AP and lateral radiographs of the entire tibia and fibula.

Adjacent Joints

Imaging should include the:

Knee

and

Ankle

because associated injuries can occur at either end of the bone.

Dedicated radiographs of these joints may be necessary when the initial tibia/fibula images do not adequately show:

Joint anatomy.

CT

CT is not routinely required for an isolated midshaft fracture but may be useful when the fracture extends into the:

Knee

or

Ankle

or when complex anatomy requires further definition.

Compartment Pressure Measurement

If acute compartment syndrome is suspected but the clinical examination is:

Uncertain

or unreliable, intracompartmental pressures may be:

Measured.

Clinical Diagnosis

Compartment syndrome remains primarily a:

Clinical diagnosis.

Pressure measurement should support, not delay, urgent treatment when the diagnosis is:

Clear.

Differential Diagnosis

The fracture itself is usually obvious.

Important issues are determining whether the fracture is:

Open

Pathologic

or associated with another:

Major injury.

Pathologic Fracture

Radiographs should be reviewed for:

Lytic lesions

Abnormal sclerosis

Cortical destruction

or other evidence of an underlying:

Bone lesion.

Open Versus Closed Injury

Careful skin inspection is essential because even a small puncture may convert the injury from:

Closed

to

Open.

Treatment

Treatment depends on:

Open versus closed status

Fracture alignment

Soft-tissue injury

Patient factors

and the ability to maintain:

Reduction.

Initial Stabilization

The injured leg should be:

Immobilized

with adequate:

Analgesia

and repeated:

Neurovascular checks.

Reduction

Grossly displaced fractures may require prompt:

Closed reduction

to restore:

Length

Alignment

and relieve pressure on:

Skin and neurovascular structures.

Closed Fractures

Selected closed fractures may be treated:

Nonoperatively

when acceptable alignment can be achieved and maintained.

Traditional Alignment Criteria

Historical criteria for nonoperative treatment include approximately:

Less than 5–7° of angulation

Less than 1 cm of shortening

and

Less than 15° of rotational deformity.

Modern decisions also consider:

Translation

Patient demands

Fracture stability

and ability to maintain alignment during:

Healing.

Long-Leg Casting

Traditional nonoperative management may begin with a:

Long-leg cast

for approximately:

3–4 weeks.

Functional Bracing

After early fracture stability develops, patients may transition to a:

Functional fracture brace

for an additional:

Several weeks.

Total duration depends on:

Radiographic and clinical healing.

Weight Bearing in Closed Treatment

Weight bearing is often restricted initially during:

Long-leg immobilization.

Progressive:

Weight bearing as tolerated

may be introduced in a functional brace when:

Fracture stability allows.

Open Fractures

Open tibial fractures require urgent:

Antibiotic administration

Tetanus assessment

Surgical irrigation and debridement

and appropriate:

Fracture stabilization.

Debridement

Surgical debridement should remove:

Contaminated

Devitalized

and clearly nonviable:

Tissue.

Open Fracture Classification

Open fractures are often described using the:

Gustilo-Anderson classification.

Type I Open Fracture

Type I generally consists of a relatively small wound with:

Limited contamination

and

Minimal soft-tissue injury.

Type II Open Fracture

Type II involves a larger wound with:

Moderate soft-tissue injury

without the extensive tissue destruction characteristic of:

Type III injuries.

Type III Open Fracture

Type III injuries involve:

High-energy trauma

with severe:

Soft-tissue damage

Contamination

or

Vascular injury.

Type IIIA

Type IIIA injuries have major soft-tissue damage but generally retain enough tissue for:

Bone coverage.

Type IIIB

Type IIIB injuries involve extensive:

Periosteal stripping

and

Soft-tissue loss

often requiring:

Flap coverage.

Type IIIC

Type IIIC fractures include an associated:

Arterial injury requiring repair.

Fixation of Open Fractures

Intramedullary nailing is commonly used for many:

Type I

Type II

and selected:

Type IIIA open fractures.

Severe Open Injuries

External fixation may be preferred initially when there is:

Severe contamination

Extensive soft-tissue loss

Vascular injury

or the need for staged:

Limb reconstruction.

Modern Staged Care

In severe open fractures, treatment frequently involves:

Serial debridement

Temporary external fixation

Soft-tissue reconstruction

and later definitive:

Internal fixation

when appropriate.

Activity

Activity depends on the method of:

Treatment.

Nonoperative Patients

Patients treated in a long-leg cast are usually initially:

Non-weight-bearing

or protected weight bearing.

Functional Brace

Once transitioned to a functional brace, progressive:

Weight bearing

may be permitted if alignment and symptoms allow.

Intramedullary Nail

After stable intramedullary fixation, many fractures can begin:

Early weight bearing as tolerated

depending on:

Fracture pattern

Fixation stability

and surgeon preference.

External Fixation

Patients with severe open fractures managed with external fixation may initially remain at:

Touch-down

or

Protected weight bearing.

Physical Therapy

Rehabilitation depends on:

Fracture stability

and

Treatment method.

Gait Training

Physical therapy assists with:

Crutches

Walker use

and progressive:

Gait training.

Knee Range of Motion

Maintaining knee motion helps prevent:

Stiffness.

Ankle Range of Motion

Ankle motion should also be preserved whenever fixation and soft-tissue conditions:

Permit.

Strengthening

Progressive strengthening is introduced as:

Fracture healing

and weight-bearing status allow.

Medication

Analgesia is required for:

Acute fracture pain.

Pain Control

Treatment may include:

Acetaminophen

NSAIDs when appropriate

and short-term:

Opioid medication

for severe pain.

Open Fracture Antibiotics

Open fractures require prompt:

Systemic antibiotics.

Antibiotic selection depends on:

Open-fracture grade

Contamination

and local:

Trauma protocols.

Surgery

Most displaced adult tibial shaft fractures are treated with:

Intramedullary nail fixation.

Intramedullary Nail

A tibial nail is a:

Load-sharing implant

placed within the:

Medullary canal.

Advantages

Intramedullary fixation provides:

Stable alignment

Preservation of soft tissues

and often allows earlier:

Mobilization and weight bearing.

Locking Screws

Proximal and distal locking screws help maintain:

Length

Rotation

and

Alignment.

External Fixation

External fixation is particularly useful for:

Severe open fractures

Major soft-tissue injury

or

Damage-control orthopaedics.

Plate Fixation

Plate fixation may be selected for certain very:

Proximal

or

Distal shaft fractures

when intramedullary fixation would not provide optimal:

Alignment or stability.

Compartment Syndrome Surgery

Confirmed acute compartment syndrome requires:

Emergency fasciotomy.

Four-Compartment Fasciotomy

Standard decompression releases all four compartments of the leg:

Anterior

Lateral

Superficial posterior

and

Deep posterior.

Follow-Up

Clinical and radiographic follow-up should continue until there is clear evidence of:

Fracture union.

Radiographic Healing

Serial radiographs assess:

Alignment

Callus formation

Hardware integrity

and progression toward:

Union.

Prognosis

Most closed tibial shaft fractures have a:

Good to excellent prognosis.

Lower-Grade Open Fractures

Type I and II open fractures also often achieve:

Good outcomes

when treated promptly and appropriately.

Severe Open Fractures

Type III open fractures carry a more:

Guarded prognosis

because of:

Soft-tissue loss

Infection risk

Vascular injury

and increased likelihood of:

Nonunion.

Complications

Major complications include:

Compartment syndrome

Anterior knee pain

Infection

Delayed union

Nonunion

Malunion

and

Chronic disability.

Compartment Syndrome

The most urgent complication is:

Acute compartment syndrome.

Failure to recognize and decompress the compartments promptly may produce:

Muscle necrosis

Permanent nerve injury

Contracture

and severe:

Functional loss.

Anterior Knee Pain

Anterior knee pain is a common complaint after:

Tibial intramedullary nailing.

Historical series have reported symptoms in up to approximately:

Half of patients.

Rates vary with:

Surgical technique

Entry point

and

Patient factors.

Infection

Infection is especially concerning after:

Open fracture.

Severe infection may progress to:

Osteomyelitis.

Delayed Union

Tibial fractures may heal slowly because of:

Soft-tissue injury

Limited blood supply in some regions

and the severity of:

Trauma.

Nonunion

Nonunion is more common in patients with:

Smoking exposure

Severe open injury

Infection

and certain:

Systemic illnesses.

Smoking

Smoking is a major modifiable risk factor for:

Delayed union

and

Nonunion.

Smoking cessation should be strongly encouraged during:

Fracture healing.

Malunion

Residual:

Varus

Valgus

Procurvatum

Recurvatum

or

Rotational deformity

may impair gait and increase stress on the:

Knee and ankle.

Functional Disability

Severe high-energy injuries may produce prolonged:

Work disability

and limitations in:

Mobility.

Historical series suggest that return to work can be substantially reduced in patients with severe:

Open fractures and major soft-tissue injury.

Patient Monitoring

Patients must be watched particularly closely during the early period for development of:

Compartment syndrome.

Serial Examinations

Repeated assessments should document:

Pain pattern

Compartment firmness

Pain with passive stretch

Motor function

Sensation

and

Perfusion.

Longer-Term Monitoring

Follow-up should also evaluate:

Fracture alignment

Union

Infection

Knee and ankle motion

and return to:

Weight bearing and function.

Key Principle

A tibial shaft fracture is a diaphyseal fracture of the tibia, most commonly produced by substantial trauma and frequently associated with fibular fracture and soft-tissue injury.

Every patient requires careful assessment for:

Open fracture, neurovascular compromise, and particularly acute compartment syndrome.

Plain radiographs of the:

Entire tibia and fibula, including the knee and ankle

are usually sufficient for diagnosis.

Stable, acceptably aligned fractures may be treated with:

Casting followed by functional bracing, whereas most displaced adult fractures are managed with:

Intramedullary nail fixation.

Open fractures require:

Prompt antibiotics, debridement, stabilization, and appropriate soft-tissue management.

The most time-critical complication is:

Compartment syndrome, while important long-term concerns include:

Infection, malunion, delayed union, nonunion, anterior knee pain, and chronic functional limitation.

Orthopaedic Surgery - Thumb Ligament Injuries

Basics

Thumb ligament injuries most commonly involve the:

Ulnar collateral ligament of the metacarpophalangeal joint.

The injury may be:

Partial

or

Complete

and frequently occurs at the ligament’s distal attachment to the:

Base of the proximal phalanx.

Mechanism

The classic mechanism is forceful:

Radial deviation

or

Abduction of the thumb MCP joint.

This places excessive tension on the:

Ulnar collateral ligament.

Radial Collateral Ligament Injury

The:

Radial collateral ligament

of the thumb MCP joint may also be injured.

This usually occurs after excessive:

Adduction

of the thumb.

RCL injuries are less common than:

UCL injuries.

Ligament Tear Versus Avulsion Fracture

The injury may consist of:

Pure ligament rupture

or

Avulsion of a small fragment of bone

from the ligament’s attachment.

Classification

Thumb collateral ligament injuries are generally classified as:

Incomplete tears

or

Complete tears

according to the integrity of the:

Ligament and its bony attachment.

Synonyms

An acute thumb MCP UCL injury is commonly called:

Skier’s thumb.

A chronic UCL injury is historically termed:

Gamekeeper’s thumb.

Skier’s Thumb

Skier’s thumb usually results from an acute:

Hyperabduction injury

such as a fall while the thumb is caught against a:

Ski pole.

Gamekeeper’s Thumb

Gamekeeper’s thumb refers to chronic attenuation or insufficiency of the:

UCL

from repetitive:

Valgus stress.

Interphalangeal Joint Injuries

Collateral ligament injuries of the thumb:

Interphalangeal joint

are less common.

The IP joint is primarily a:

Hinge joint

and injuries may include:

Collateral ligament sprain

or

Dislocation.

Trapeziometacarpal Joint Injuries

Ligament injuries of the:

Trapeziometacarpal joint

are also less common.

They are often associated with:

CMC dislocation or subluxation.

Important TMC Ligaments

TMC dislocation may injure the:

Dorsoradial ligament

and

Anterior oblique ligament.

These structures contribute substantially to:

Thumb CMC stability.

Prevention

Prevention centers on avoiding mechanisms that force the thumb into excessive:

Abduction

or

Adduction.

Sports Prevention

Athletes should avoid situations where the thumb becomes caught during:

Falls

Ball handling

or contact with:

Equipment.

Epidemiology

Thumb ligament injuries occur in:

Men and women

and can affect:

All age groups.

Risk Factors

Common risk factors include:

Skiing accidents

and sports involving:

Ball handling

or sudden:

Thumb impact.

Associated Sports

Examples include:

Baseball

Football

and

Basketball.

Etiology

The classic UCL injury is caused by forceful:

Radial deviation of the thumb.

This produces excessive tension on the ligament and may result in:

Partial tearing

Complete rupture

or

Bony avulsion.

Associated Conditions

A UCL injury may be associated with:

Avulsion fracture

or a:

Stener lesion.

Stener Lesion

A Stener lesion occurs when a completely ruptured:

Ulnar collateral ligament

retracts proximally and becomes displaced superficial to the:

Adductor aponeurosis.

Importance of a Stener Lesion

The interposed adductor aponeurosis prevents the torn ligament from returning to its normal:

Anatomic insertion.

As a result, spontaneous healing is unlikely.

Clinical Clues to a Stener Lesion

Patients may demonstrate:

Marked swelling

Ecchymosis

and sometimes a palpable:

Ulnar-sided mass

at the MCP joint.

Diagnosis

Diagnosis is based on:

History

Physical examination

and

Imaging.

Signs and Symptoms

Typical symptoms include:

Pain

Swelling

and

Bruising

along the:

Ulnar side of the thumb MCP joint.

Deformity

Some patients have visible deformity near the:

Ulnar base of the thumb.

Functional Loss

Patients frequently report difficulty with:

Pinching

Gripping

and

Opening containers.

Loss of stable pinch is especially characteristic of significant:

UCL insufficiency.

Physical Examination

Examine the thumb for:

Swelling

Ecchymosis

Tenderness

and palpable:

Abnormality.

Palpable Mass

A local ulnar-sided mass may represent:

Retracted ligament

Stener lesion

or

Avulsed bone fragment.

Stability Testing

The MCP joint should be stressed in:

Extension

and at approximately:

30° of flexion.

Testing in Extension

Valgus stress in full or near-full extension assesses both:

Accessory collateral ligament structures

and overall:

MCP stability.

Testing in Flexion

Testing at approximately:

30° of MCP flexion

better isolates the:

Proper ulnar collateral ligament.

Comparison With the Opposite Thumb

Stability should be compared with the:

Contralateral uninjured thumb.

Complete Tear

Findings suggesting a complete tear include:

Absence of a firm endpoint

or approximately:

More than 15° greater laxity than the opposite side.

Absolute angular thresholds vary because normal ligament laxity differs between:

Individuals.

The quality of the endpoint is therefore especially important.

Radiographs Before Stress Examination

Plain radiographs should be reviewed before aggressive:

Stress testing.

This is important because an associated fracture may be displaced by:

Forceful examination.

Digital Block

In acute injuries, pain and swelling may prevent reliable examination.

A:

Digital nerve block

may allow more accurate assessment of:

Ligament stability.

TMC Joint Examination

The trapeziometacarpal joint should also be examined when clinically indicated.

The examiner translates the:

First metacarpal

relative to the:

Trapezium.

TMC Instability

Pain and excessive translation suggest:

CMC ligament injury.

Imaging

Plain Radiographs

Acute thumb injuries should undergo plain radiography to assess for:

Fracture

and

Joint alignment.

Avulsion Fracture

Radiographs may demonstrate a small bony fragment at the:

Base of the proximal phalanx

corresponding to:

UCL avulsion.

Chronic Injuries

In chronic ligament insufficiency, radiographs help assess for:

Joint subluxation

and

Degenerative arthritis.

Stress Radiographs

Stress radiographs may occasionally demonstrate:

Abnormal MCP opening

although they are less commonly required when examination and advanced imaging are:

Diagnostic.

MRI

MRI provides detailed information regarding:

Ligament continuity

Retraction

Stener lesion

and associated:

Cartilage or joint damage.

Ultrasound

Ultrasound may also assess:

Ligament integrity

and can identify displacement suggestive of a:

Stener lesion.

Its accuracy depends considerably on:

Operator experience.

Pathological Findings

Pathology may demonstrate:

Attenuation

or

Complete rupture

of the UCL.

Displaced Ligament

In a Stener lesion, the torn ligament lies superficial to the:

Adductor aponeurosis

rather than adjacent to its normal:

Distal insertion.

Differential Diagnosis

Important alternatives include:

First metacarpal fracture

Proximal phalanx fracture

First CMC arthritis

and

Volar plate injury.

Treatment

Treatment depends on:

Ligament involved

Completeness of rupture

Joint stability

Fracture displacement

and whether the injury is:

Acute or chronic.

Incomplete UCL Tear

Partial tears can generally be treated:

Nonoperatively.

Acute Partial Tear

Initial treatment includes:

Rest

Elevation

Ice

Analgesia

and

Thumb-spica immobilization.

Immobilization Duration

A partial ligament tear is commonly immobilized for approximately:

4 weeks.

If an associated stable avulsion fracture is present, immobilization may continue for up to:

6 weeks.

Chronic Partial Injury

Chronic but stable symptoms may be treated with:

Thumb-spica bracing

Activity modification

and rehabilitation.

Persistent instability may require:

Elective repair or reconstruction.

Complete UCL Tear

A complete acute rupture, particularly one associated with:

Instability

or

Stener lesion

generally requires:

Surgical repair.

Avulsion Fracture

Treatment of an avulsion fracture depends on:

Fragment size

Displacement

and

Joint stability.

Options include:

Ligament repair

Fracture fixation

or selected:

Fragment excision.

Stener Lesion

A confirmed Stener lesion requires:

Operative treatment

because the interposed:

Adductor aponeurosis

prevents normal ligament healing.

Chronic Complete Tear

Delayed or chronic complete tears frequently require:

Ligament reconstruction

rather than simple:

Primary repair.

Radial Collateral Ligament Injuries

RCL injuries are managed according to similar principles.

RCL Tear Location

Unlike UCL injuries, RCL injuries more commonly occur at the:

Proximal attachment.

Stener Equivalent

A true:

Stener lesion

does not occur with RCL rupture because the same interposition mechanism is:

Absent.

TMC Joint Injury

A stable TMC ligament injury may be treated with:

Immobilization.

Unstable TMC Joint

An acutely unstable TMC injury may require:

Reduction

and temporary:

Pin fixation.

Chronic TMC Instability

Chronic instability may require:

Ligament reconstruction

such as reconstruction of the:

Anterior oblique ligament

depending on the specific pattern.

Physical Therapy

Therapy is particularly important after:

Surgery.

Rehabilitation Goals

Treatment focuses on restoring:

Range of motion

Pinch strength

Grip strength

and safe progression back to:

Activity.

Internal Brace Rehabilitation

When ligament repair is augmented with a:

Suture-tape internal brace

selected patients may begin protected motion:

Earlier

than with traditional repair alone.

Medication

Pain can generally be managed with:

Acetaminophen

NSAIDs

or other short-term:

Nonopioid analgesia.

Natural Resolution of Pain

Even with appropriate immobilization, swelling and discomfort may persist for:

Several weeks.

Surgery

Acute MCP collateral ligament injuries that require surgery are usually treated with:

Direct suture repair.

Primary Repair

A complete acute tear can often be repaired directly to the:

Proximal phalanx

using:

Suture anchors

or

Bone tunnels.

Internal Brace

A:

Suture-tape internal brace

may be added to reinforce the repair and potentially permit:

Earlier rehabilitation.

Delayed Presentation

When diagnosis is delayed for approximately:

One month or longer

fibrosis and tissue retraction may make primary repair:

Difficult or impossible.

Reconstruction

Chronic injuries may require:

Local tendon advancement

Tendon graft

or

Fascial graft reconstruction.

Late Arthritis

Pain or crepitus during grinding of the MCP joint may indicate development of:

Posttraumatic arthritis.

MCP Arthrodesis

For painful advanced MCP arthritis with chronic instability:

Arthrodesis

may provide reliable:

Pain relief and stability.

TMC Arthritis

Chronic TMC injury complicated by advanced arthritis may be treated with procedures such as:

Arthrodesis

or

Trapeziectomy-based reconstruction

depending on the patient’s:

Age

Functional requirements

and

Arthritic pattern.

Follow-Up

After ligament repair or reconstruction, the thumb is commonly immobilized for approximately:

4–6 weeks.

Removable Splinting

After the initial healing phase, patients may transition to:

Removable splinting

with guided:

Range-of-motion exercises.

Strengthening

Progressive strengthening begins after sufficient:

Ligament healing

and restoration of:

Motion.

Return to Activity

Return to sport or unrestricted use is based on restoration of:

Stability

Strength

Motion

and

Pain-free function.

Prognosis

The prognosis after appropriate acute repair is generally:

Good to excellent.

Acute Injuries

Early recognition and treatment of complete UCL rupture provide the best chance for:

Stable healing

and restoration of:

Pinch strength.

Chronic Injuries

Chronic injuries can also achieve good outcomes after:

Reconstruction

although treatment is usually more technically:

Complex.

Complications

Potential complications include:

Chronic instability

Persistent pain

Nonunion of an avulsion fragment

and

Degenerative joint disease.

Chronic Instability

Untreated complete ligament rupture may result in persistent:

MCP laxity

and weak:

Pinch function.

Avulsion Nonunion

An avulsed bone fragment may fail to unite, leading to:

Pain

or persistent:

Instability.

Posttraumatic Arthritis

Longstanding joint incongruity or instability may cause:

Degenerative arthritis.

Surgical Complications

Other potential complications include:

Stiffness

Sensory nerve irritation

Recurrent instability

and

Repair failure.

Patient Monitoring

Follow-up should be performed by the:

Orthopaedic or hand surgeon

until healing and functional recovery are:

Complete.

Follow-Up Interval

Patients may be reviewed approximately every:

4–8 weeks

during the healing period.

Monitoring Goals

Assessment should include:

Joint stability

Range of motion

Pinch strength

Grip strength

and return to:

Normal activity.

Key Principle

Thumb ligament injuries most commonly involve the ulnar collateral ligament of the MCP joint, usually after forceful:

Thumb abduction.

Acute injury is termed:

Skier’s thumb, whereas chronic UCL insufficiency is historically called:

Gamekeeper’s thumb.

A complete tear is suggested by:

Marked instability and loss of a firm endpoint, while a:

Stener lesion

occurs when the avulsed UCL becomes trapped superficial to the adductor aponeurosis and therefore cannot heal normally.

Partial stable injuries are generally treated with:

Thumb-spica immobilization, whereas complete unstable tears and Stener lesions usually require:

Surgical repair.

Early recognition is important to prevent:

Chronic instability, weak pinch, and posttraumatic arthritis.

Orthopaedic Surgery - Thumb Arthritis

Basics

Thumb arthritis most commonly affects the:

Carpometacarpal joint of the thumb

also known as the:

Basal joint.

The disorder results primarily from progressive loss of:

Articular cartilage

at the articulation between the:

First metacarpal

and

Trapezium

together with varying degrees of:

Ligamentous insufficiency.

Clinical Presentation

Patients commonly present with:

Pain

Swelling

Stiffness

and reduced:

Thumb function.

Functional Disability

Functional limitation is often prominent because the thumb CMC joint is essential for:

Grip

Pinch

Opposition

and many:

Activities of daily living.

Patients may specifically report difficulty with:

Opening jars

Turning keys

Twisting lids

Gripping objects

or maintaining a firm:

Pinch or grasp.

Primary Osteoarthritis

The most common underlying disorder is:

Primary osteoarthritis.

The thumb CMC joint is one of the hand joints frequently affected by:

Degenerative arthritis.

Other Arthritides

The thumb may also be involved in:

Rheumatoid arthritis

Gout

and

Posttraumatic arthritis.

Anatomy and Biomechanics

The thumb CMC joint is a:

Saddle-shaped joint

that permits a large range of motion.

Its movements include:

Flexion

Extension

Abduction

Adduction

and

Opposition.

Mechanical Stress

Because the CMC joint combines:

High mobility

with substantial:

Pinch and grip forces

it is exposed to significant mechanical loading throughout:

Daily activities.

Ligamentous Support

Ligamentous structures help maintain:

Joint congruity

and

Stability.

Progressive ligamentous laxity can contribute to:

Subluxation

and abnormal loading of the:

Articular cartilage.

Epidemiology

Thumb CMC arthritis occurs most commonly in:

Middle-aged and older adults.

Age

Symptomatic disease commonly becomes apparent from approximately the:

Fifth decade of life onward.

Sex

The supplied source describes involvement of:

Men and women.

In clinical practice, radiographic and symptomatic basal-joint osteoarthritis is commonly encountered in:

Women after midlife.

Risk Factors

No single risk factor is required for the development of:

Primary osteoarthritis.

Potential contributors include:

Age-related cartilage degeneration

Joint laxity