Orthopaedic Surgery - Foot and Ankle Anatomy and Examination

Basics

For normal function, the foot should be plantigrade, meaning that it rests evenly on the ground, and it should permit painless weight bearing and propulsion.

Foot and ankle function depends on coordinated activity of both extrinsic muscles, which originate in the leg, and intrinsic muscles, which originate within the foot.

Extrinsic Muscles

The major extrinsic muscle-tendon groups can be divided functionally into dorsiflexors, evertors, plantarflexors, and invertors.

Dorsiflexors

The principal anterior extensor tendons include the tibialis anterior, extensor digitorum longus, peroneus tertius, and extensor hallucis longus.

These tendons cross superficially over the anterior ankle and are readily palpable.

Because of their superficial position, they are vulnerable to laceration from sharp objects.

Evertors

The primary evertors are the peroneus longus and peroneus brevis.

Their muscle bellies lie along the lateral leg, and their tendons pass posterior to the lateral malleolus.

Damage to the peroneal tendon sheath or superior peroneal retinaculum may allow the tendons to subluxate or dislocate over the lateral malleolus.

Plantarflexors and Invertors

Several important tendons pass posteromedial to the ankle.

The posterior tibial tendon is the major dynamic inverter and an important supporter of the medial longitudinal arch.

In adults, posterior tibial tendon degeneration, tenosynovitis, or rupture can contribute to adult-acquired flatfoot deformity.

Extrinsic Toe Flexors

The major extrinsic flexors of the toes are the flexor digitorum longus and flexor hallucis longus.

They contribute to toe flexion and assist with propulsion during gait.

Intrinsic Foot Muscles

The intrinsic muscles consist of one dorsal layer and three plantar layers.

Together, they control fine toe movements, support the arches, and contribute to balance and stabilization during stance.

Muscle Imbalance

An imbalance between intrinsic and extrinsic muscle forces may contribute to deformities such as hammer toes, claw toes, and mallet toes.

Bony Anatomy

Most bones and major bony landmarks of the foot and ankle are readily palpable, making systematic examination particularly useful.

The foot is conventionally divided into the hindfoot, midfoot, and forefoot.

Ankle Joint

The ankle, or tibiotalar joint, is formed by the articulation of the distal tibia, fibula, and talus.

It primarily permits plantarflexion and dorsiflexion.

Range of Motion

Normal ankle motion is approximately 40° of plantarflexion and 20° of dorsiflexion, although values vary among individuals.

Ankle Ligaments

Syndesmotic Ligaments

The distal tibiofibular syndesmosis is stabilized by the anterior and posterior tibiofibular ligaments, together with other components of the syndesmotic complex.

Injury to this complex produces a high ankle sprain.

Deltoid Ligament

The superficial and deep portions of the deltoid ligament extend from the medial malleolus to the talus, calcaneus, and navicular region.

They provide important medial ankle stability.

Lateral Ligament Complex

The lateral ankle is supported by the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL).

The ATFL is the ligament most commonly injured during a typical inversion ankle sprain.

Hindfoot

The hindfoot consists principally of the talus and calcaneus.

These bones articulate at the subtalar joint.

Subtalar Motion

The subtalar joint permits inversion and eversion, with an overall motion arc of approximately 40°.

This motion allows the foot to adapt to irregular or uneven surfaces.

Talus

The talus is covered extensively by articular cartilage and has a relatively vulnerable blood supply.

Fracture or major subtalar dislocation can disrupt its vascular supply and lead to avascular necrosis.

Calcaneus

The calcaneus is the major weight-bearing bone of the heel and acts as an important shock absorber.

An axial load after a fall from height is a classic mechanism of calcaneal fracture.

Midfoot

The midfoot is organized into two principal rows.

Proximally, the navicular and cuboid articulate with the hindfoot.

Distally, the three cuneiforms and cuboid articulate with the metatarsals through the tarsometatarsal joints.

Tarsometatarsal Complex

Ligaments connect most adjacent metatarsal bases.

A notable exception exists between the first and second metatarsal bases, where there is no strong direct intermetatarsal ligament.

Lisfranc Ligament

The strong Lisfranc ligament extends from the medial cuneiform to the base of the second metatarsal.

It is a key stabilizer of the tarsometatarsal complex.

Forefoot

The forefoot consists of five metatarsals and 14 phalanges.

These structures contribute to balance, load distribution, and propulsion.

Gait Cycle

The gait cycle can be divided into stance and swing phases.

Stance Phase

The stance phase consists broadly of heel strike, foot-flat or midstance, and toe-off.

Heel Strike

At heel strike, the tibialis anterior and long toe extensors are active.

The foot undergoes pronation, which increases midfoot flexibility and allows better absorption of impact and accommodation to the ground.

Foot Flat

As weight progresses over the foot, the posterior tibialis and peroneal muscles contribute to dynamic control.

External rotation of the leg and subsequent foot supination help make the midfoot more rigid and stable for weight bearing.

Toe-Off

During push-off, the gastrocnemius-soleus complex becomes highly active.

This produces plantarflexion and propels the body forward.

Windlass Mechanism

Dorsiflexion of the toes, particularly the great toe, tightens the plantar fascia.

This windlass mechanism elevates the medial longitudinal arch and increases midfoot rigidity.

The foot is thereby converted from a flexible shock absorber into a stable lever for push-off.

Swing Phase

During swing, the tibialis anterior and long toe extensors remain active to dorsiflex the ankle and prevent the toes from dragging.

Clinical History

A thorough history should establish the nature of the patient’s symptoms and relevant systemic factors.

Acute Injury

For trauma, the mechanism should be documented carefully because it can suggest the injured bone, ligament, tendon, or joint.

Pain

Pain should be characterized according to severity, location, quality, radiation, duration, aggravating factors, and relieving factors.

Mechanical Symptoms

Locking, catching, clicking, giving way, or instability may suggest an intra-articular or ligamentous abnormality.

Neurologic Symptoms

The patient should be asked about numbness, dysesthesia, tingling, burning, or weakness.

Relevant Medical History

Important conditions include diabetes mellitus, neurologic disease, peripheral vascular disease, and inflammatory arthritis.

Surgical History

Previous surgery involving the foot, ankle, leg, or associated joints should be documented.

Functional History

Shoe wear, occupation, sports participation, and recreational activities can provide important information about repetitive loading and functional demands.

Physical Examination

The involved extremity should always be compared with the contralateral side.

The examination should be performed both standing and seated when possible.

Standing Examination

Alignment

While the patient stands, foot and ankle alignment should be observed.

Viewed from behind, the hindfoot can be categorized as varus, neutral, or valgus.

Too-Many-Toes Sign

When more lateral toes are visible from behind on the affected side than on the opposite side, the finding is called the too-many-toes sign.

This suggests forefoot abduction associated with collapse of the medial arch, as seen in flatfoot deformity.

Gait

The patient’s gait should be observed for abnormalities such as steppage gait, circumduction, scissoring, or an antalgic pattern.

Heel Rise

Double- and single-leg heel-rise testing evaluates dynamic foot function.

It helps assess posterior tibial tendon strength, arch reconstitution, hindfoot inversion, and balance.

Seated Examination

Vascular Examination

The dorsalis pedis pulse is palpated on the dorsum of the foot, typically just lateral to the extensor hallucis longus tendon.

The posterior tibial pulse is palpated posterior to the medial malleolus.

Venous Status

The foot and ankle should also be examined for pitting edema, venous stasis changes, skin discoloration, and other evidence of vascular insufficiency.

Sensory Examination

Sensation should be assessed according to peripheral nerve distribution.

Superficial Peroneal Nerve

The superficial peroneal nerve supplies most of the dorsum of the foot.

Deep Peroneal Nerve

The deep peroneal nerve is tested in the first dorsal web space.

Saphenous Nerve

The saphenous nerve supplies the medial border of the foot.

Sural Nerve

The sural nerve supplies the lateral border of the foot.

Tibial Nerve

The plantar surface of the foot is supplied primarily through branches of the tibial nerve.

Protective Sensation

The ability to perceive a 5.07 Semmes-Weinstein monofilament on the plantar surface correlates with protective sensation.

Loss of this sensation is particularly important in patients with diabetic or other peripheral neuropathy.

Neurologic Examination

Deep tendon reflexes should be assessed when appropriate.

The examination may also include evaluation for Babinski response and clonus when upper motor neuron disease is suspected.

Motor Examination

Strength testing should be combined with palpation of the corresponding tendons.

Ankle Dorsiflexion

Dorsiflexion primarily tests the tibialis anterior.

Ankle Plantarflexion

Plantarflexion is generated mainly by the gastrocnemius-soleus complex.

Eversion

Eversion evaluates the peroneal muscles.

Inversion

Inversion, especially with the foot slightly plantarflexed, assesses the posterior tibial tendon.

Great Toe Motion

Flexion of the distal phalanx of the great toe assesses the flexor hallucis longus, while extension tests the extensor hallucis longus.

Range of Motion

Both active and passive motion should be evaluated.

Ankle Motion

Ankle plantarflexion and dorsiflexion should be measured, preferably with any correctable hindfoot deformity brought into a neutral position.

Subtalar Motion

Hindfoot inversion and eversion assess the mobility of the subtalar joint.

Chopart Joint

Abduction and adduction through the transverse tarsal, or Chopart, joint can be assessed while stabilizing the hindfoot.

Lisfranc Joint

The tarsometatarsal complex should be palpated and stressed gently with plantarflexion and dorsiflexion of the metatarsals.

Pain or instability may indicate a Lisfranc injury.

Metatarsophalangeal and Toe Joints

Motion of the MTP and interphalangeal joints should be assessed for stiffness, instability, pain, and deformity.

Palpation

Systematic palpation helps localize pathology.

Malleoli

The medial and lateral malleoli should be palpated for tenderness suggestive of fracture or ligament injury.

Ankle Joint

The ankle joint should be assessed for joint-line tenderness or effusion, which may suggest synovitis or an osteochondral lesion.

Posterior Tibial Tendon

The posterior tibial tendon should be palpated from behind the medial malleolus to its insertion on the navicular.

Tenderness may indicate posterior tibial tendinitis or tendon dysfunction.

Navicular Tuberosity

The navicular tuberosity is located approximately 2 cm distal and plantar to the medial malleolus.

Tenderness in this region may reflect an accessory navicular, navicular stress fracture, posterior tibial tendon insertional pathology, or talonavicular disorder.

Achilles Tendon

The Achilles tendon and retrocalcaneal bursa should be palpated along the posterior ankle and hindfoot.

The examiner should look for defects, nodules, thickening, swelling, or tenderness suggestive of tendinopathy or rupture.

Peroneal Tendons

The peroneal tendons should be palpated posterior to the lateral malleolus.

The peroneus brevis can be followed to the base of the fifth metatarsal, while the peroneus longus passes beneath the foot through a groove near the cuboid.

Tenderness may reflect tendinitis or associated fifth-metatarsal pathology.

Peroneal Subluxation

The ankle can be circumducted while the tendons are observed and palpated for abnormal subluxation over the lateral malleolus.

Sinus Tarsi

The sinus tarsi lies approximately 1 cm distal to the lateral malleolus.

Tenderness may suggest subtalar joint inflammation or instability.

Syndesmosis

Tenderness between the distal tibia and fibula just proximal to the ankle joint raises concern for a syndesmotic, or high ankle, sprain.

Plantar Fascia

The plantar fascia should be palpated from its origin at the plantar calcaneus.

Tenderness near the medial plantar heel that becomes more pronounced with toe dorsiflexion is characteristic of plantar fasciitis.

Lisfranc Region

Tenderness at the base of the second metatarsal is concerning for a Lisfranc injury.

Plantar ecchymosis in this region is particularly significant.

Sesamoids

The plantar aspect of the great-toe MTP joint should be examined for tenderness related to sesamoiditis or sesamoid fracture.

Lesser Metatarsal Heads

Tenderness beneath the lesser MTP joints may indicate metatarsalgia.

Intermetatarsal Spaces

Tenderness in the metatarsal interspaces, sometimes accompanied by radiating paresthesias into the toes, may suggest an interdigital neuroma.

Special Tests

Anterior Drawer Test

The anterior drawer test assesses lateral ankle instability, particularly the ATFL.

The examiner stabilizes the distal tibia and translates the heel and talus anteriorly relative to the tibia.

The ATFL is stressed most effectively with the ankle in slight plantarflexion, whereas testing nearer neutral places relatively greater contribution on the broader lateral ligament complex.

Excessive anterior translation or a soft endpoint compared with the opposite ankle suggests instability.

Thompson Test

The Thompson test evaluates integrity of the Achilles tendon.

With the patient prone and the foot hanging freely, the examiner squeezes the calf.

An intact Achilles tendon produces plantarflexion of the foot.

Failure of plantarflexion strongly suggests Achilles tendon rupture.

Lesser-Toe Deformities

Mallet, hammer, and claw toe deformities should be assessed systematically.

Calluses

The location of callus formation helps identify areas of abnormal pressure.

Flexibility

The examiner should determine whether the deformity is flexible and manually correctable or rigid and fixed.

MTP Stability

A modified drawer test can assess MTP joint instability by attempting to translate and reduce the proximal phalanx relative to the metatarsal head.

Hallux Valgus Examination

Calluses and Medial Eminence

Callus formation and tenderness over the medial eminence should be documented.

MTP Motion

Range of motion of the first MTP joint should be assessed with the valgus deformity gently corrected.

This helps identify associated arthritis or stiffness.

First Tarsometatarsal Hypermobility

The lateral forefoot is stabilized while the first metatarsal is translated dorsally and plantarly.

Excessive mobility suggests first tarsometatarsal joint hypermobility.

Lesser-Toe Deformities

Associated lesser-toe deformities should be identified because they may contribute to pain and influence treatment planning.

Laboratory Tests

Laboratory testing is generally guided by the suspected diagnosis.

Suspected Infection

When infection is a concern, laboratory studies may include white blood cell count, erythrocyte sedimentation rate, and C-reactive protein.

Joint Aspiration

Synovial fluid from a suspicious joint should be sent for cell count with differential, Gram stain, culture, and crystal analysis.

Imaging

Plain Radiographs

Radiographs are the first-line imaging study for most structural foot and ankle disorders.

Acute Trauma

When acute fracture or dislocation is suspected and the patient cannot safely stand, non-weight-bearing radiographs are appropriate.

Weight-Bearing Radiographs

When the patient can stand safely, weight-bearing views are generally preferred for evaluation of alignment and deformity.

Standing radiographs demonstrate bony relationships under physiologic load and may reveal pathology that is not apparent on non-weight-bearing images.

Stress Radiographs

Stress views can indirectly assess the integrity of ligamentous structures by demonstrating abnormal joint translation or widening under applied force.

CT

CT provides excellent bony detail and is particularly useful for complex fracture patterns and disorders of the midfoot and hindfoot.

It is valuable for evaluating articular congruity and planning reconstruction.

MRI

MRI is especially useful for soft-tissue and occult osseous disorders.

It can demonstrate tendon and ligament injuries, soft-tissue masses, subtle fractures, marrow abnormalities, and infection.

Bone Scintigraphy

Technetium-99m bone scintigraphy can help localize pathology when pain is vague or multifocal.

It may detect stress fractures, tumors, and other metabolically active skeletal abnormalities, although MRI is often more specific for many modern indications.

General Examination Principles

A complete foot and ankle assessment combines history, standing alignment, gait analysis, vascular and neurologic examination, muscle testing, range of motion, palpation, provocative maneuvers, and appropriately selected imaging.

Because disorders of one region frequently alter mechanics elsewhere, the entire lower extremity should be considered rather than evaluating only the painful site.

Orthopaedic Surgery - Flexor Tendon Laceration

Basics

Flexor tendon lacerations may occur anywhere along the volar surface of the fingers, palm, wrist, or forearm.

They are commonly described according to the anatomic zone of injury because tendon anatomy, repair technique, rehabilitation, and prognosis vary substantially by location.

Flexor Tendon Zones

For the fingers, flexor tendon injuries are traditionally divided into Zones I through V.

The thumb has a corresponding three-zone classification.

Zone I

Zone I extends from the fingertip proximally to the proximal interphalangeal (PIP) flexion crease.

In this region, the flexor digitorum profundus (FDP) is the principal flexor tendon because the flexor digitorum superficialis (FDS) inserts more proximally.

Zone II

Zone II extends from the PIP flexion crease proximally to the distal palmar transverse crease near the A1 pulley.

Both the FDS and FDP tendons travel together within the flexor sheath in this region.

Zone II: “No-Man’s Land”

Zone II was historically called “no-man’s land” because repairs in this region were associated with a particularly high risk of postoperative adhesions, scarring, and poor tendon gliding.

The anatomy is complex because both the superficial and deep flexor tendons pass through a confined fibro-osseous pulley system.

Modern repair techniques and early mobilization protocols have substantially improved outcomes, but Zone II injuries remain technically demanding.

Zone III

Zone III extends from the distal palmar transverse crease proximally to the distal wrist flexion crease or transverse carpal ligament.

Zone IV

Zone IV corresponds to the carpal tunnel.

Multiple flexor tendons and the median nerve are closely packed within this confined space, so associated injuries may be substantial.

Zone V

Zone V is located proximal to the carpal tunnel, extending into the distal forearm.

Lacerations in this region may involve multiple tendons together with the median or ulnar nerves and major vessels.

Classification

Flexor tendon injuries are described according to both the specific tendon injured and the zone of injury.

They may involve the FDS, FDP, flexor pollicis longus, or combinations of these structures.

Function

Each flexor tendon contributes to finger strength, coordinated motion, and independent digital control.

The FDS primarily flexes the PIP joint, whereas the FDP flexes the DIP joint and also contributes to flexion of more proximal joints.

Epidemiology

Approximately 25% of flexor tendon lacerations occur in the workplace.

Males are affected substantially more often than females, with reported male-to-female ratios of approximately 3–6:1.

Risk Factors

The principal risk factor is occupational or recreational exposure to sharp objects or machinery.

Etiology

Most injuries result from a sharp penetrating mechanism such as a knife, broken glass, sheet metal, or other cutting object.

Crush or high-energy injuries may produce more extensive tendon and soft-tissue damage and generally have a worse prognosis.

Associated Injuries

Flexor tendon lacerations may occur with injuries to adjacent structures.

Digital Nerve Injury

Digital nerve laceration accompanies approximately one-quarter of flexor tendon injuries in some series.

Digital Artery Injury

Digital arteries may also be disrupted, potentially compromising perfusion of the involved finger.

Pulley Injury

The annular or cruciate pulley system may be damaged, particularly in deeper lacerations.

Pulley loss can impair tendon gliding and produce bowstringing.

Joint Injury

A laceration may penetrate the flexor tendon sheath or enter the interphalangeal or metacarpophalangeal joint, producing a traumatic arthrotomy.

Fracture

Associated phalangeal or metacarpal fractures may occur, particularly with high-energy mechanisms.

Diagnosis

Signs and Symptoms

The typical injury is a laceration over the palmar aspect of the finger, hand, or wrist.

Loss of tendon continuity alters the resting posture of the finger.

Change in Finger Posture

The injured finger may rest in greater extension than the adjacent digits because normal flexor tendon tension has been lost.

Comparison with the opposite hand and neighboring fingers is useful.

Loss of Active Flexion

The patient may be unable to actively flex the joint controlled by the injured tendon.

The exact deficit depends on whether the FDS, FDP, or both have been divided.

Loss of Tenodesis

Normally, passive wrist extension causes the fingers to flex because of the tenodesis effect.

Loss of this automatic finger flexion may indicate flexor tendon disruption.

Wrist Squeeze Test

In children or uncooperative patients, squeezing the forearm or flexor muscle mass can produce passive finger flexion when the tendons are intact.

Failure of the expected motion raises concern for tendon injury.

Physical Examination

A careful examination should be completed before local anesthesia whenever possible so that motor, sensory, and vascular function can be accurately documented.

Flexor Digitorum Profundus Testing

To test the FDP, the examiner stabilizes the PIP joint and other proximal joints in extension while asking the patient to actively flex the DIP joint.

Ability to flex the DIP indicates an intact FDP tendon.

Failure suggests FDP disruption or dysfunction.

Flexor Digitorum Superficialis Testing

To isolate the FDS, the examiner holds the other fingers in full extension and asks the patient to flex the finger being tested.

With the other digits immobilized, the tested finger should primarily flex at the PIP joint.

Failure to flex the PIP suggests FDS injury, although anatomic variations must be considered.

Strength Testing

Each finger should be assessed individually for flexion strength.

Weakness may indicate a partial tendon injury even when active motion remains present.

Tenodesis Examination

The wrist is passively moved through flexion and extension while the examiner observes the normal cascade of the fingers.

Abnormal movement suggests disruption of the flexor mechanism.

Vascular Examination

Perfusion must be assessed carefully.

Evaluation may include capillary refill, skin color, temperature, pulse oximetry, and Doppler assessment.

A poorly perfused or dysvascular digit is a surgical emergency.

Sensory Examination

Adjacent digital nerves should be tested before anesthetic injection.

Light touch and two-point discrimination are particularly useful for identifying digital nerve injury.

Wound Exploration

The wound should be carefully evaluated for evidence of partial or complete tendon injury, pulley disruption, foreign material, fracture, and joint penetration.

Exploration should be performed in a controlled fashion to avoid additional damage.

Imaging

Plain Radiographs

Radiographs should be obtained when there is concern for fracture, dislocation, bony avulsion, or retained radiopaque foreign body.

Ultrasound

Ultrasound can identify tendon discontinuity and may be useful when the physical examination is uncertain.

MRI

MRI can also demonstrate flexor tendon injury but is rarely necessary when the history and examination clearly establish the diagnosis.

Differential Diagnosis

Phalangeal Fracture-Dislocation

A fracture or dislocation involving the phalanx or interphalangeal joint can produce pain and loss of active flexion that resembles tendon injury.

Tendon Avulsion

A tendon may be avulsed from its insertion without an open laceration.

An important example is FDP avulsion from the distal phalanx.

Tendon Rupture

Closed tendon rupture can also result in loss of flexion.

Pulley Rupture

Pulley disruption may cause pain and abnormal tendon mechanics while preserving some active flexion.

Initial Treatment

Vascular Assessment

The first priority is to determine whether the finger and hand are adequately perfused.

A dysvascular digit or hand requires emergent operative evaluation.

Severe Associated Injury

Open fractures, major tissue loss, vascular injury, or gross contamination also require urgent surgical management.

Tetanus Prophylaxis

Tetanus immunization status should be reviewed and prophylaxis administered when indicated.

Wound Irrigation

The wound should be thoroughly irrigated with normal saline and gross contamination removed.

Antibiotics

Antibiotic administration depends on contamination, mechanism of injury, open fracture, bite exposure, and other risk factors.

A perioperative intravenous dose may be given for selected injuries according to local protocols.

Elevation and Splinting

The hand should be elevated and placed in a protective splint until definitive surgical assessment is completed.

Specialist Consultation

Early consultation with a hand surgeon or orthopaedic surgeon experienced in tendon repair is appropriate.

Factors Affecting Management

Treatment planning should consider hand dominance, occupation, time since injury, injury zone, tendon involvement, associated neurovascular injury, contamination, and patient comorbidities.

Physical Therapy and Hand Therapy

Postoperative hand therapy is an essential part of treatment.

The goal is to protect the repair while restoring tendon glide and preventing stiffness and adhesions.

Timing

Passive motion is commonly initiated within approximately 3–5 days after surgery, depending on the strength of the repair and the rehabilitation protocol.

Early Active Motion

Early active-motion protocols are increasingly used when a sufficiently strong repair has been achieved and the patient can follow restrictions reliably.

Immobilization

Children, cognitively impaired patients, or adults who cannot comply with movement restrictions may require more prolonged immobilization to protect the repair.

Surgery

Timing of Repair

Primary repair generally provides the best functional outcome.

Repair is preferably performed during the acute period, often within approximately 7–10 days of injury.

Delayed primary repair may still be possible, but direct repair becomes more difficult as tendon retraction, scarring, and muscle shortening develop.

Chronic Injuries

Injuries older than approximately 3–4 weeks often cannot be treated with straightforward primary repair and may require tendon grafting, staged reconstruction, or other reconstructive techniques.

Anesthesia

Repair may be performed under general anesthesia, regional anesthesia, or wide-awake local anesthesia without tourniquet (WALANT), depending on injury pattern and surgeon preference.

Flexor Tendon Sheath Injury

When the flexor tendon sheath is also disrupted, timely repair is desirable because excessive scarring can impair tendon gliding and worsen the functional result.

Surgical Exploration

The wound is extended as necessary to identify the full extent of injury.

The surgeon evaluates the tendon, pulley system, nerves, vessels, joints, and bone.

Minimizing Tissue Trauma

Meticulous technique is important because additional surgical trauma promotes scar formation and adhesions.

Sequence of Repair

After all injuries have been identified, flexor tendon repair is generally completed before nerve and vascular repair.

Tendon Repair Technique

A variety of core suture patterns can be used.

The repair must provide enough strength for early motion while remaining sufficiently smooth and compact to glide through the tendon sheath and pulley system.

Core Sutures

Repair strength generally increases with the number of core suture strands crossing the repair site.

Modern repairs commonly use at least four core strands, with some techniques using six or more.

Epitendinous Suture

An additional circumferential epitendinous suture is commonly placed to improve repair strength and smooth the tendon surface.

Zone II Repair

Zone II injuries require particular attention because both the FDS and FDP pass through the pulley system.

FDP

The FDP is repaired to restore DIP flexion and overall digital function.

FDS

Depending on tendon damage, available space within the sheath, and intraoperative tendon gliding, the surgeon may repair both FDS slips, one slip, or neither, balancing strength against the risk of excessive bulk and adhesions.

Postoperative Splinting

A dorsal blocking splint is typically applied after repair.

The wrist is generally maintained in neutral to slight flexion, the MCP joints are flexed to approximately 70°, and the interphalangeal joints are kept near extension.

Hand Therapy

The splint is removed or adjusted under controlled conditions during supervised hand therapy, which commonly begins within 3–5 days.

The exact rehabilitation protocol depends on the injury zone and strength of repair.

Follow-Up

Prognosis

Outcome depends strongly on the location, mechanism, severity, and associated injuries.

Clean sharp lacerations generally have a better prognosis than crush, avulsion, contaminated, or high-energy injuries.

Zone II Prognosis

Zone II injuries remain particularly prone to postoperative stiffness and adhesion formation because of the complex tendon-pulley anatomy.

Complications

Loss of Motion

Reduced range of motion may result from scar formation, tendon adhesions, joint stiffness, or inadequate rehabilitation.

Adhesions

Adhesions can tether the repaired tendon to surrounding tissue and limit active flexion despite preserved passive motion.

Loss of Strength

Persistent weakness may occur even after successful healing.

Infection

Infection may complicate contaminated wounds, open fractures, joint injuries, or tendon sheath injuries.

Tendon Rerupture

The repair may rupture if excessive force is applied before adequate healing occurs.

Rerupture may require repeat repair or reconstruction.

Delayed Reconstruction

Severe scarring, chronic tendon loss, failed primary repair, or rerupture may necessitate tendon grafting, staged tendon reconstruction, or tendon transfer.

Patient Monitoring

Follow-up should closely assess wound healing, vascular status, tendon integrity, active and passive range of motion, scar formation, adhesion development, strength, and compliance with splinting and therapy.

Early recognition of excessive stiffness or repair failure allows rehabilitation or surgical planning to be modified before permanent functional loss develops.

Orthopaedic Surgery - Flatfoot

Basics

Flatfoot, or pes planus, is a condition in which the normal medial longitudinal arch of the foot is reduced or absent.

It may be an asymptomatic normal variant or a painful deformity caused by an underlying structural, neurologic, inflammatory, degenerative, or tendon-related disorder.

Normal Development

A flat-appearing foot is common in infants and young children because the medial longitudinal arch is not yet fully developed.

Physiologic flatfoot may therefore be normal up to approximately 5 years of age.

Classification

Flatfoot can be classified according to flexibility and according to whether it develops during childhood or adulthood.

Flexible Flatfoot

A flexible flatfoot demonstrates loss of the medial arch during weight bearing.

The arch reappears when the patient is non-weight bearing or rises onto the toes.

The hindfoot remains mobile and its valgus alignment can generally correct toward neutral or varus.

Rigid Flatfoot

A rigid flatfoot lacks a normal medial arch both during weight bearing and when the foot is unloaded.

Hindfoot motion is restricted, and valgus deformity does not correct with toe standing.

Rigid flatfoot is more likely to reflect an underlying structural abnormality.

Pediatric Versus Adult Flatfoot

The age at onset provides important diagnostic information.

Pediatric flatfoot is commonly developmental or congenital, whereas adult-onset deformity more often results from posterior tibial tendon dysfunction, arthritis, neuropathic disease, or previous trauma.

Epidemiology

Congenital Flexible Flatfoot

Flexible flatfoot commonly runs in families, although the precise inheritance pattern is uncertain.

Persistent flexible flatfoot has been reported in approximately 14% of adults.

Tarsal Coalition

Tarsal coalition is an important cause of congenital or developmental rigid flatfoot.

Some forms demonstrate familial inheritance, classically described as autosomal dominant with variable penetrance.

Reported prevalence varies widely, from less than 1% to more than 10%, partly because many cases remain asymptomatic.

Adult-Acquired Flatfoot

Posterior tibial tendon dysfunction is one of the most common causes of acquired flatfoot in adults.

The exact population incidence is uncertain.

Risk Factors

Flexible Pediatric Flatfoot

A positive family history increases the likelihood of persistent flexible flatfoot.

Tarsal Coalition

Family history is an important risk factor for tarsal coalition.

Some reports have also described a higher frequency in females.

Posterior Tibial Tendon Dysfunction

Risk factors for adult-acquired flatfoot related to posterior tibial tendon degeneration include hypertension, diabetes mellitus, obesity, and previous trauma.

Other Predisposing Conditions

Additional disorders associated with flatfoot include a tight Achilles tendon, neurologic or neuromuscular disease, inflammatory arthritis, osteoarthritis, post-traumatic arthritis, and Charcot neuroarthropathy.

Neurologic causes may include conditions such as spina bifida, myelodysplasia, stroke, or other disorders affecting muscle balance and foot mechanics.

Etiology

Congenital Flexible Flatfoot

Flexible pediatric flatfoot is usually developmental and may have a familial predisposition.

Tarsal Coalition

Tarsal coalition results from abnormal congenital connection between two or more tarsal bones.

The connection may be fibrous, cartilaginous, or osseous.

Posterior Tibial Tendon Dysfunction

Adult-acquired flatfoot commonly results from degeneration, attenuation, elongation, or rupture of the posterior tibial tendon.

As tendon function deteriorates, the medial arch progressively collapses and the hindfoot drifts into valgus.

Charcot Neuroarthropathy

Flatfoot resulting from Charcot neuroarthropathy develops because of bone fragmentation, resorption, fracture, joint instability, and progressive collapse.

Other Causes

Other important causes include congenital vertical talus, peroneal spastic flatfoot, previous trauma, and severe structural deformity.

Diagnosis

Signs and Symptoms

The most obvious feature is a low or absent medial longitudinal arch.

Some patients remain completely asymptomatic.

Others develop pain, fatigue, swelling, or progressive deformity.

Pain

Pain is commonly felt along the medial arch or medial ankle.

Symptoms may worsen with prolonged walking, sports, high levels of activity, or following trauma.

Progressive Deformity

Some forms of flatfoot gradually worsen with time, particularly adult-acquired flatfoot related to posterior tibial tendon dysfunction.

Shoe Wear

Abnormal loading may produce increased wear along the medial aspect of the shoe.

History

The history should establish age at onset, progression, family history, activity level, previous trauma, neurologic or systemic disease, and associated pain or swelling.

Pediatric History

Pediatric flexible flatfoot is often noted from an early age.

Parents may report fatigue, decreased endurance, difficulty participating in sports, or pain after prolonged activity.

Adult-Acquired Flatfoot

Posterior tibial tendon dysfunction commonly presents as gradually progressive aching and swelling along the medial ankle and foot.

With progression, the foot may flatten and abduct, and walking becomes increasingly difficult.

Physical Examination

Determining Flexibility

The most important initial examination step is determining whether the flatfoot is flexible or rigid.

This distinction substantially narrows the differential diagnosis and influences treatment.

Rigid Flatfoot

In rigid flatfoot, the medial longitudinal arch remains absent during both weight bearing and non-weight bearing.

Hindfoot motion is limited, and the valgus deformity does not correct when the patient rises onto the toes.

Flexible Flatfoot

In flexible flatfoot, the arch disappears during standing but reconstitutes when the foot is unloaded or during toe standing.

The hindfoot remains mobile and usually moves from valgus toward neutral or varus with heel rise.

Forefoot Abduction

Increasing deformity may produce lateral deviation of the forefoot relative to the hindfoot.

This creates the characteristic “too many toes” sign when the patient is viewed from behind.

Posterior Tibial Tendon Examination

Resisted Inversion

Strength of inversion should be tested against resistance.

Weakness or inability to invert the foot may indicate posterior tibial tendon dysfunction.

Single-Leg Heel Rise

The patient is asked to rise onto the toes while standing on the affected limb.

Pain, weakness, inability to perform the maneuver, or failure of the hindfoot to move into varus suggests posterior tibial tendon insufficiency.

Inspection and Palpation

The foot should be inspected for arch collapse, hindfoot valgus, forefoot abduction, swelling, callosities, and asymmetry.

Tenderness should be localized carefully, particularly along the posterior tibial tendon, subtalar region, midfoot, and medial arch.

Gait Examination

Gait should be observed for pain, weakness, or abnormal propulsion.

Antalgic Gait

A painful limp may suggest arthritis, tendon inflammation, stress injury, or another painful structural disorder.

Posterior Tibial Tendon Dysfunction

Patients with posterior tibial tendon dysfunction may demonstrate reduced push-off and impaired propulsion.

Neurologic Gait

An awkward or foot-slapping gait raises concern for an underlying neurologic or neuromuscular disorder.

Achilles Tendon

The Achilles tendon should be assessed for tightness.

Limited ankle dorsiflexion caused by gastrocnemius-Achilles contracture can worsen a flatfoot deformity and contribute to symptoms.

Imaging

Weight-Bearing Radiographs

Imaging should be obtained while the patient is standing whenever possible because deformity is best appreciated under physiologic load.

Standard evaluation may include weight-bearing AP, lateral, and oblique views of the foot, with ankle views when ankle or hindfoot pathology is suspected.

Calcaneal Pitch

The calcaneal pitch decreases as the medial longitudinal arch collapses.

In severe flatfoot it may approach 0°.

Talus–First Metatarsal Angle

The relationship between the talus and first metatarsal can be assessed on weight-bearing radiographs.

Normally, these structures are nearly collinear.

Increasing angular divergence reflects progressive arch collapse.

Severity

Historically, an angle of approximately 15° or less has been considered mild, 15–30° moderate, and greater than 30° severe, although interpretation depends on the exact measurement method and clinical context.

Imaging for Tarsal Coalition

Oblique Radiographs

An oblique foot radiograph may demonstrate a calcaneonavicular coalition.

CT

CT is particularly useful for defining a talocalcaneal coalition, determining its extent, and assessing associated degenerative change.

Arthritis

Cross-sectional imaging can also assess the degree of subtalar, hindfoot, or midfoot arthritis.

Imaging for Charcot Arthropathy

Radiographs should be evaluated for fragmentation, collapse, subluxation, sclerosis, and resorption, all of which may indicate Charcot neuroarthropathy.

MRI

MRI is useful for evaluating posterior tibial tendon degeneration, tenosynovitis, partial tearing, or rupture.

It can also assess associated ligament and soft-tissue pathology.

Pathological Findings

Charcot Neuroarthropathy

Pathologic changes include bone fragmentation, fracture, resorption, and progressive joint collapse.

Posterior Tibial Tendon Dysfunction

The tendon may demonstrate degeneration, thickening, attenuation, tenosynovitis, or tearing.

Tarsal Coalition

A coalition may consist of fibrous, fibrocartilaginous, or osseous tissue between adjacent tarsal bones.

Differential Diagnosis

Pediatric Flatfoot

Important pediatric causes include benign flexible flatfoot, tarsal coalition, congenital vertical or oblique talus, and accessory navicular.

Adult-Acquired Flatfoot

In adults, the differential diagnosis includes posterior tibial tendon dysfunction or rupture, midfoot arthritis, Charcot neuroarthropathy, and neuromuscular disease.

Treatment

General Principles

Asymptomatic flatfoot does not require treatment.

Education and reassurance are appropriate, particularly in children with benign flexible flatfoot.

Treatment is directed toward symptoms and the underlying cause rather than the appearance of the foot alone.

Pediatric Flexible Flatfoot

Asymptomatic Children

No treatment is necessary when the child has painless, flexible flatfoot with normal function.

Activity-Related Pain

If symptoms occur with activity, supportive shoes may be helpful.

A prefabricated or custom medial arch support can be considered for comfort.

Orthoses

Orthotic devices may reduce symptoms in some children, but they do not reliably create a permanent arch or alter the natural structural development of the foot.

Evidence supporting routine use in asymptomatic children is limited.

Tarsal Coalition

Initial treatment of a symptomatic coalition may include rest, temporary activity restriction, NSAIDs, and immobilization in a below-knee cast or walking boot.

Immobilization

Short-term immobilization may substantially reduce pain by limiting motion across the symptomatic coalition.

Tight Achilles Tendon

Flatfoot associated with a tight heel cord may improve symptomatically with Achilles and gastrocnemius stretching.

Physical therapy can assist with a structured stretching program.

Adult-Acquired Flatfoot From Posterior Tibial Tendon Dysfunction

Initial treatment may include rest, NSAIDs, temporary immobilization, orthotic support, bracing, and weight reduction when appropriate.

Immobilization

An acute painful episode may be treated with a below-knee cast or walking boot to reduce tendon loading.

Long-Term Support

Custom arch supports or an ankle-foot orthosis may help control hindfoot valgus and support the medial arch.

Corticosteroid Injection

Direct corticosteroid injection into the posterior tibial tendon is generally avoided because of concern for tendon weakening or rupture.

Midfoot Arthritis

Treatment may include orthotic arch support, NSAIDs, footwear modification, rocker-bottom soles, stiff or steel-shank shoes, and selected intra-articular corticosteroid injections.

Charcot Arthropathy

Acute Phase

Acute Charcot neuroarthropathy requires off-loading and immobilization, commonly with a total-contact cast or equivalent protective device.

Weight bearing may need to be restricted depending on severity.

Long-Term Management

After the acute inflammatory phase settles, custom orthoses, bracing, and protective footwear may be required.

Surgery is reserved for severe deformity, instability, recurrent ulceration, or failure of nonoperative treatment.

Physical Therapy

Physical therapy can improve ankle and foot mobility, strength, gait, and Achilles flexibility.

It is particularly useful when heel-cord tightness contributes to symptoms.

Orthotic Services

An orthotist may fabricate custom arch supports or braces when more substantial mechanical control is needed.

Medication

NSAIDs may be useful when pain and swelling are significant.

They are particularly helpful during episodes of posterior tibial tendinitis, arthritis, or other inflammatory symptoms.

Surgery

Surgery is rarely required for uncomplicated flexible flatfoot.

It is considered when there is persistent pain despite appropriate conservative treatment, progressive deformity, instability, or rigid structural abnormality.

Surgical Planning

The choice of procedure depends on patient age, activity level, deformity flexibility, degree of arthritis, underlying cause, and medical comorbidities.

Procedures may include soft-tissue reconstruction, osteotomy, coalition resection, or arthrodesis.

Pediatric Flexible Flatfoot Surgery

When surgery is required for a symptomatic flexible deformity, treatment generally involves osteotomies designed to restore alignment, correct hindfoot valgus, and improve foot mechanics.

Soft-tissue procedures may be added when necessary.

Tarsal Coalition Surgery

Coalition Resection

A symptomatic coalition that fails conservative treatment may be resected.

Interposition of fat, muscle, or another tissue may be used to reduce the risk of reformation.

Subtalar Arthrodesis

If a talocalcaneal coalition involves a large portion of the subtalar joint, historically more than approximately 50%, or if substantial degenerative arthritis is present, subtalar fusion may be preferred over resection.

Achilles Tendon Lengthening

Persistent equinus caused by a tight Achilles tendon may require surgical lengthening.

Techniques include Z-lengthening or controlled partial tendon lengthening, depending on severity and age.

Posterior Tibial Tendon Surgery

Early Disease

In early posterior tibial tendon disease with relatively preserved tendon structure and alignment, synovectomy or debridement may occasionally be sufficient.

Flexible Deformity

Flexible adult-acquired flatfoot may require a combination of tendon transfer, calcaneal osteotomy, midfoot osteotomy, ligament reconstruction, or limited arthrodesis.

Rigid Deformity

When the deformity becomes rigid or significant arthritis is present, fusion procedures are often required.

Follow-Up

Prognosis

Most patients with flexible flatfoot do not develop progressive deformity and never require corrective surgery.

Children with asymptomatic flexible flatfoot generally have an excellent prognosis.

Adult-Acquired Flatfoot

Posterior tibial tendon dysfunction is an important exception because it may progressively worsen from a flexible deformity to a rigid arthritic flatfoot if untreated.

Complications

Most patients managed nonoperatively have little risk of major complications.

Persistent pain, worsening deformity, arthritis, callus formation, and reduced mobility may occur when the underlying disorder progresses.

Posterior Tibial Tendon Dysfunction

Progressive tendon insufficiency may cause increasing hindfoot valgus, forefoot abduction, arch collapse, ligament failure, and eventually rigid deformity with arthritis.

Patient Monitoring

Follow-up frequency depends on the underlying cause and severity.

Symptomatic or progressive patients may be reassessed at approximately 3-month intervals initially.

Monitoring should document pain, function, arch height, hindfoot alignment, flexibility, single-leg heel-rise ability, gait, shoe wear, and progression of deformity.

Orthopaedic Surgery - Fibrous Dysplasia

Basics

Fibrous dysplasia is a benign fibro-osseous disorder in which normal mature lamellar bone is replaced by immature woven bone and fibrous tissue.

The abnormal bone has reduced mechanical strength and may progressively deform under normal loading.

Clinical Characteristics

The condition can produce focal or multifocal defects in bone quality, progressive skeletal deformity, pain, and pathologic fracture.

Patients with polyostotic disease may also have associated endocrine abnormalities.

Café-au-Lait Pigmentation

Café-au-lait skin lesions are particularly associated with multifocal disease and McCune–Albright syndrome.

The lesions classically have irregular borders that have been compared with the “coast of Maine.”

Endocrine Manifestations

Endocrine abnormalities may appear early in childhood.

Precocious puberty may develop during the first years of life and can occasionally be evident as early as infancy.

Classification

Fibrous dysplasia is classified according to the extent of skeletal involvement.

Monostotic fibrous dysplasia involves a single bone.

Polyostotic fibrous dysplasia affects multiple bones and may show asymmetric involvement, often with greater disease burden on one side of the body.

Terminology

Fibrous dysplasia should not be confused with osteitis fibrosa cystica, which is a different skeletal disorder associated with hyperparathyroidism.

Epidemiology

Fibrous dysplasia is uncommon.

Males and females are affected approximately equally.

Risk Factors and Syndromic Association

McCune–Albright Syndrome

The classic McCune–Albright syndrome consists of the triad of:

Polyostotic fibrous dysplasia, café-au-lait skin pigmentation, and precocious puberty.

Other endocrine abnormalities may also occur.

Genetics and Etiology

Fibrous dysplasia results from a postzygotic activating mutation involving the GNAS gene, which encodes the alpha subunit of a stimulatory G protein.

This abnormality leads to excessive intracellular cyclic adenosine monophosphate (cAMP) signaling.

Mosaic Distribution

Because the mutation occurs after fertilization, affected patients have a mosaic distribution of abnormal cells.

The earlier in embryonic development the mutation occurs, the more extensive the disease is likely to be.

This explains why some patients have a single skeletal lesion while others have widespread skeletal and endocrine involvement.

Associated Conditions

Fibrous dysplasia may be associated with various endocrinopathies, particularly in polyostotic disease and McCune–Albright syndrome.

Rarely, malignant transformation may occur, most commonly to osteosarcoma and less often to fibrosarcoma or other sarcomas.

Diagnosis

Diagnosis is often suggested strongly by the characteristic radiographic appearance.

In typical lesions, plain radiographs may be sufficiently characteristic that biopsy is unnecessary.

Signs and Symptoms

Skeletal Deformity

Progressive deformity may develop in involved bones, particularly the proximal femur, pelvis, and craniofacial skeleton.

Because the abnormal bone is mechanically weak, repeated loading can gradually produce bowing.

Neurologic Compromise

Cranial or spinal lesions may occasionally cause neurologic symptoms through deformity or compression of neural structures.

Pain

Patients may experience a chronic dull ache in affected bones, particularly during weight bearing.

Approximately one-third of patients develop chronic pain.

Gait Abnormality

Lower-extremity deformity can produce a limp or waddling gait.

This may be especially apparent with bilateral proximal femoral or pelvic involvement.

Scoliosis

Spinal involvement or asymmetric lower-extremity deformity may contribute to scoliosis.

Physical Examination

Height

The patient’s height should be measured and followed over time, particularly when endocrine disease or extensive skeletal involvement is present.

Spinal Examination

The spine should be examined for scoliosis, kyphosis, or other progressive deformity.

Limb Length and Alignment

Limb lengths and angular deformities should be measured.

All four extremities should be inspected for bowing or asymmetry.

Hip Examination

Hip range of motion should be carefully documented, particularly in patients with proximal femoral involvement.

Loss of motion may reflect progressive deformity or associated pain.

Palpation

Areas of known disease should be palpated for tenderness, swelling, or increased warmth.

New or increasing tenderness warrants reassessment.

Gait

The patient’s gait should be observed for limping, waddling, limb-length inequality, or mechanical abnormalities caused by deformity.

Laboratory Tests

There is no single laboratory test that confirms isolated fibrous dysplasia.

Laboratory investigation is directed toward associated endocrine abnormalities when clinically suspected.

Endocrine Evaluation

Depending on the presentation, testing may include growth hormone, thyroid function, adrenal function, phosphate metabolism, and sex-hormone evaluation.

Further endocrine testing should be individualized.

Imaging

Plain Radiographs

The classic radiographic appearance is a relatively homogeneous “ground-glass” matrix.

This reflects the replacement of normal trabecular bone by immature woven bone and fibrous tissue.

Distribution in Long Bones

Fibrous dysplasia often extends over a long segment of the diaphysis and may involve nearly the entire shaft.

A traditional description is that fibrous dysplasia is a “long lesion in a long bone.”

Cortical Changes

The involved bone may demonstrate cortical thinning and expansion while maintaining a relatively smooth outer contour.

The lesion often blends gradually with surrounding normal bone rather than having a sharply defined border.

Shepherd’s Crook Deformity

A classic complication involving the proximal femur is the shepherd’s crook deformity.

This consists of progressive varus and bowing of the proximal femur caused by repeated loading of weakened dysplastic bone.

Consequences

The deformity increases bending stress across the proximal femur and may lead to worsening angulation, pain, shortening, gait disturbance, and fracture.

Bone Scintigraphy

Technetium bone scintigraphy may be used to identify additional skeletal lesions in patients with suspected polyostotic disease.

Fibrous dysplasia lesions are usually metabolically active and therefore often appear “hot”, although uptake can vary.

CT

CT is particularly useful for evaluating craniofacial lesions, spinal involvement, complex deformity, and surgical anatomy.

It provides excellent detail of cortical structure and osseous expansion.

Pathological Findings

Histologically, affected bone contains multiple small, irregular, disorganized trabeculae of immature woven bone within a fibrous stroma.

Alphabet-Soup Appearance

The irregular trabeculae are often described as resembling “alphabet soup” because of their curved and randomly arranged configuration.

Fibrous Marrow

Normal marrow is replaced by fibrous connective tissue.

The abnormal trabeculae fail to form the organized architecture required for normal mechanical strength.

Osteoblastic Rimming

Typical lesions lack prominent osteoblastic rimming around the abnormal trabeculae.

The bone forms through fibro-osseous metaplasia rather than normal lamellar remodeling.

Differential Diagnosis

Unicameral Bone Cyst

A unicameral bone cyst may produce a lucent lesion and pathologic fracture, particularly in younger patients.

Its central location and lack of a ground-glass matrix usually help distinguish it.

Fibrous Cortical Defect

Fibrous cortical defects are typically small, eccentric, cortical-based metaphyseal lesions rather than long intramedullary abnormalities.

Ollier Disease

Ollier disease produces multiple enchondromas with a characteristic cartilaginous appearance rather than the ground-glass matrix of fibrous dysplasia.

Treatment

General Principles

Treatment is determined by symptoms, deformity, fracture risk, location of disease, and associated endocrine abnormalities.

Many asymptomatic lesions can be observed.

Skeletal Deformity

Progressive deformity should be corrected when it causes pain, functional impairment, or increasing mechanical disadvantage.

Endocrinopathy

Associated endocrine disorders should be treated appropriately because hormonal abnormalities can worsen skeletal disease and contribute to deformity or fracture risk.

Craniofacial Reconstruction

Severe craniofacial deformity may require reconstructive surgery when there is substantial cosmetic deformity, functional impairment, or compression of adjacent structures.

Pain Management

Pain can be treated with appropriate analgesics.

Patients with persistent or complex pain may benefit from consultation with a pain-management specialist.

Bisphosphonates

Bisphosphonates have historically been used in selected patients with significant bone pain, although their effect on lesion progression or deformity is limited.

They should not be expected to restore normal bone architecture.

Activity

Increasing activity alone does not strengthen dysplastic bone.

Patients should generally use pain and mechanical symptoms as guides to activity.

High-Impact Activity

High-impact and prolonged endurance activities may increase the risk of fracture in significantly involved weight-bearing bones.

Activity recommendations should therefore reflect lesion severity and mechanical stability.

Physical Therapy

Physical therapy is most useful for postoperative rehabilitation, gait training, maintenance of mobility, and muscle strengthening.

Patients with involvement of several limbs may require individualized therapy because deformities can affect multiple segments simultaneously.

Surgery

General Orthopaedic Principles

The goals of surgery are to correct deformity, restore mechanical alignment, support weakened bone, and reduce the risk of fracture.

Correction of Bowing

Marked bowing should be corrected because deformity increases bending forces and promotes further progression.

Proximal Femoral Deformity

In the proximal femur, corrective procedures may include valgus-producing osteotomy or medial displacement osteotomy, depending on the pattern of deformity.

Mechanical Support

Dysplastic bone should be supported with durable fixation.

Metal implants or structural cortical grafts are generally more reliable than cancellous graft alone.

Intramedullary Fixation

An intramedullary device is usually preferred to a plate when feasible.

Because the implant lies near the mechanical axis and spans a long segment of bone, it provides more effective protection against bending forces and fatigue failure.

Plate Fixation

Plate constructs may be less advantageous in extensive disease because they protect only a localized segment and are exposed to greater bending stress.

Bone Grafting

Simple bone grafting alone often fails because the underlying dysplastic process can recur or replace the graft.

Complete removal of all abnormal tissue is generally unnecessary.

Cortical Allograft

Structural cortical allograft may be preferred when grafting is required because it provides mechanical support and remodels more slowly.

Cancellous Autograft

Autogenous cancellous graft is less useful because it may be rapidly resorbed and replaced by fibrous dysplastic tissue.

Operative Bleeding

Fibrous dysplasia lesions can bleed substantially during surgery.

Preoperative planning should therefore account for possible significant blood loss.

Follow-Up

Prognosis

Disease behavior varies considerably.

Some lesions remain stable after skeletal maturity, whereas others may continue to deform or become symptomatic in adulthood.

New lesions or progression can occasionally occur after skeletal maturity.

Chronic Pain

Approximately one-third of patients may experience chronic skeletal pain.

Polyostotic Disease

Patients with extensive polyostotic disease may have greater morbidity because of skeletal deformity, fractures, endocrinopathy, immobility, and associated systemic complications.

Complications

Fracture

Pathologic fracture is a common mechanical complication because dysplastic bone has reduced structural strength.

Chronic Pain

Persistent pain can substantially affect mobility, function, mood, and quality of life.

Depression

Chronic deformity and pain may contribute to depression and other psychological consequences.

Malignant Transformation

Malignant transformation is rare, occurring in roughly 1% or less of cases in most series.

The most common secondary malignancy is osteosarcoma, although fibrosarcoma and other sarcomas can occur.

Warning Signs of Malignancy

Concerning features include a sudden increase in pain, rapid enlargement of a previously stable lesion, new swelling, increased warmth, cortical destruction, or a new soft-tissue mass.

These findings warrant urgent reassessment.

Patient Monitoring

Patients should be followed periodically by clinicians familiar with the disorder so that progressive deformity and complications can be identified early.

Orthopaedic Surveillance

Patients with significant lower-extremity or spinal involvement may benefit from annual orthopedic review, particularly to monitor proximal femoral bowing and scoliosis.

Long-Term Monitoring

Follow-up should include assessment of pain, gait, limb alignment, limb length, scoliosis, fracture history, endocrine abnormalities, and functional status.

Patients should also be educated regarding the warning signs of malignant transformation and instructed to seek evaluation for any sudden change in a previously stable lesion.

Orthopaedic Surgery - Fibrous Cortical Defect / Nonossifying Fibroma

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Basics

A nonossifying fibroma (NOF) is a common benign developmental bone lesion seen primarily in children and adolescents with open physes.

Despite its name, the lesion typically undergoes progressive mineralization and involution as skeletal maturity is reached.

When the lesion is very small and confined mainly to the cortex, it is commonly termed a fibrous cortical defect.

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Typical Location

NOFs arise eccentrically within the metaphysis of long bones.

The most common locations are the distal femur, proximal tibia, and distal tibia.

The lesion is characteristically associated with the growing skeleton and usually regresses or becomes incorporated into normal bone by adulthood.

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Staging

Like other benign bone lesions, NOFs can be described according to biologic activity.

Stage 1, or latent lesions, account for the great majority, approximately 96%.

Stage 2, or active lesions, represent roughly 2–3%.

Stage 3, or aggressive lesions, are very uncommon, accounting for less than 1%.

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Natural History

During childhood, some lesions may behave as active stage 2 abnormalities.

With skeletal maturation, they generally become latent and progressively ossify.

Ultimately, most disappear radiographically or leave only a residual area of sclerosis.

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Synonyms

Other names that have been used include benign metaphyseal cortical defect, metaphyseal fibrous defect, benign fibrous histiocytoma, and fibrous xanthoma.

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Epidemiology

NOF is one of the most common benign skeletal lesions of childhood.

It has been estimated to occur in approximately 35% of otherwise healthy children with open growth plates.

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Proposed Mechanism

The exact cause is uncertain.

One proposed explanation is a localized disturbance of cortical remodeling with increased periosteal resorption during growth.

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Associated Conditions

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Neurofibromatosis

Lesions resembling NOFs may occasionally occur in patients with neurofibromatosis, with reported frequencies of approximately 5%.

Their clinical context should therefore be considered when multiple or atypical lesions are present.

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Jaffe–Campanacci Syndrome

Jaffe–Campanacci syndrome is a rare congenital disorder characterized by multiple, often widespread and relatively symmetric NOF-like lesions.

Associated findings may include café-au-lait pigmentation, other nonskeletal abnormalities, and developmental or intellectual impairment.

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Diagnosis

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Signs and Symptoms

Most fibrous cortical defects and NOFs are completely asymptomatic.

They are typically discovered incidentally when radiographs are obtained for trauma or another unrelated complaint.

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Pain

Pain is unusual unless the lesion has weakened the bone sufficiently to cause an impending or completed pathologic fracture.

New weight-bearing pain therefore warrants further evaluation.

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Physical Examination

Most lesions are nontender and produce no visible abnormality.

There should generally be no swelling or pain with weight bearing unless the bone has become structurally compromised.

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Examination for Associated Syndromes

When multiple lesions are present, the patient should be examined for features of neurofibromatosis or Jaffe–Campanacci syndrome, including café-au-lait pigmentation and other systemic abnormalities.

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Imaging

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Plain Radiographs

Plain radiographs usually establish the diagnosis.

The classic appearance is an eccentric radiolucent lesion arising from the cortex of the metaphysis of a long bone.

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Common Sites

The distal femur, proximal tibia, and distal tibia are particularly common locations.

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Cortical Appearance

The lesion is cortical based.

The overlying cortex may become thinned, particularly in larger lesions, but it is usually preserved unless fracture occurs.

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Sclerotic Margin

A characteristic scalloped rim of reactive sclerotic bone surrounds the lesion.

This well-defined border is an important feature of its benign appearance.

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Multiloculated Appearance

Many lesions have a multiloculated or lobulated configuration, producing a characteristic “bubbly” appearance on radiographs.

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Size

Lesions may range from only a few millimeters to several centimeters.

A very small lesion is generally termed a fibrous cortical defect, whereas a larger lesion extending into the medullary cavity is more often called an NOF.

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Number of Lesions

Most NOFs are solitary, although more than one lesion may occur in the same patient or in multiple bones.

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Bone Scintigraphy

If bone scintigraphy is performed, an active lesion may demonstrate increased tracer uptake because of the reactive bone along its periphery.

As the lesion heals and becomes inactive, scintigraphic activity generally decreases and may return to normal.

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MRI

MRI is not routinely required when the radiographic appearance is characteristic.

It can, however, be useful when there is concern for a stress fracture, pathologic fracture, or atypical lesion.

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Pathological Findings

Histologically, the lesion consists predominantly of fibrous connective tissue arranged in a whorled or storiform pattern.

This appearance has sometimes been described as having a “starry-night” quality.

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Cellular Components

Additional findings may include multinucleated giant cells, lipid-laden or foamy histiocytes, and hemosiderin deposition.

True cystic spaces are not a typical feature.

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Differential Diagnosis

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Chondromyxoid Fibroma

Chondromyxoid fibroma can also present as a metaphyseal lytic lesion and may need to be distinguished from NOF when the imaging appearance is atypical.

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Giant Cell Tumor

Giant cell tumor generally occurs in skeletally mature patients and has a different distribution, often extending to the epiphysis.

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Fibrous Dysplasia

Fibrous dysplasia may produce an intramedullary lucent or ground-glass lesion and should be considered when the lesion is not classically cortical and eccentric.

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Treatment

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General Principles

Most NOFs require no treatment because they are benign and spontaneously involute with skeletal maturity.

Observation is appropriate for asymptomatic lesions with a typical radiographic appearance.

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Activity

Children with small, asymptomatic lesions may participate in normal activities without restriction.

Routine limitation of sports or weight bearing is unnecessary.

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New Weight-Bearing Pain

If a child develops new pain during weight bearing, AP and lateral radiographs should be obtained to look for an occult or stress fracture.

MRI is useful if radiographs are inconclusive but clinical suspicion remains high.

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Observation

Large asymptomatic lesions may be followed radiographically until sufficient healing or skeletal maturity occurs.

The exact frequency depends on lesion size and fracture risk.

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Follow-Up of Large Lesions

Children with larger lesions may be reviewed approximately every 6 months, particularly when a substantial portion of the cortex is involved.

Monitoring may continue until the lesion becomes sclerotic or growth is complete.

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Small Lesions

A small, asymptomatic lesion involving less than approximately 25% of the cortical width generally does not require routine serial surveillance when the diagnosis is secure.

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Fracture Risk

The principal clinical concern is pathologic fracture.

Risk increases when a lesion occupies a large portion of the bone diameter or substantially weakens the cortex.

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Lesions Involving More Than 50% of the Cortex

If more than approximately 50% of the cortical width is involved and the patient is symptomatic, the risk of pathologic fracture is increased.

Such lesions require closer observation and may warrant operative treatment.

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Protected Weight Bearing

When an impending pathologic fracture is suspected, the child should avoid unrestricted loading.

Non-weight bearing or protected weight bearing may be recommended until definitive management is determined.

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Surgery

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Indications

Surgery is generally reserved for lesions with impending pathologic fracture, substantial structural weakness, persistent symptoms, or selected completed fractures.

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Curettage

The lesion can be treated by curettage, removing the fibrous tissue from the involved bone.

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Bone Grafting

After curettage, the defect is usually filled with bone graft or another suitable bone substitute to restore structural strength.

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Internal Fixation

Internal fixation is usually unnecessary because most lesions heal readily after curettage and grafting.

Fixation may be considered only when fracture stability or lesion size makes additional support necessary.

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Follow-Up

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Prognosis

The prognosis is excellent.

Virtually all typical fibrous cortical defects and NOFs undergo spontaneous healing and sclerosis by skeletal maturity.

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Complications

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Pathologic Fracture

Pathologic fracture is uncommon.

It occurs primarily in large lesions involving more than approximately half of the bone diameter, particularly when the patient has pain or sustains significant trauma.

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Malignant Transformation

Typical NOFs do not undergo malignant transformation.

An aggressive or progressively destructive appearance should prompt reconsideration of the diagnosis rather than being interpreted as expected NOF behavior.

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Patient Monitoring

When follow-up is required, serial AP and lateral radiographs are used to document lesion stability, progressive sclerosis, cortical strengthening, and eventual involution.

Patients should be reassessed sooner if they develop new pain, swelling, difficulty bearing weight, or symptoms suggesting fracture.

Orthopaedic Surgery - Femoroacetabular Impingement

Basics

Femoroacetabular impingement (FAI) results from abnormal contact between the femoral head-neck junction and the acetabular rim during hip motion.

Repeated impingement can produce hip pain and functional limitation, particularly in young and active patients.

Over time, abnormal contact may damage the acetabular labrum and adjacent articular cartilage and may contribute to the development of hip osteoarthritis.

Classification

FAI is classified according to whether the predominant structural abnormality arises from the femur, acetabulum, or both.

The three principal patterns are cam, pincer, and mixed impingement.

Cam Impingement

Cam impingement results from an abnormal contour of the femoral head-neck junction.

Instead of maintaining a smooth spherical transition between the femoral head and neck, the proximal femur develops a prominence that contacts the acetabular rim during hip flexion and rotation.

Femoral Abnormalities

Associated findings may include a decreased femoral head-neck ratio, reduced head-neck offset, femoral neck retroversion, and an aspherical femoral head.

These abnormalities reduce clearance between the femur and acetabulum.

Mechanism of Damage

During flexion and internal rotation, the abnormal femoral prominence enters the acetabulum and may shear the adjacent labrum and cartilage.

Repeated loading can lead to progressive chondrolabral injury.

Pincer Impingement

Pincer impingement results from excessive acetabular coverage of the femoral head.

The acetabular rim contacts the femoral neck earlier than normal during hip motion.

Acetabular Abnormalities

Potential causes include acetabular retroversion, acetabular protrusio, coxa profunda, and excessive focal or global acetabular rim coverage.

Mechanism of Damage

Repeated contact between the acetabular rim and femoral neck may damage the labrum.

A countercoup cartilage lesion may also develop posteriorly in some patients because the femoral head is levered within the socket.

Mixed Impingement

Many patients demonstrate both femoral and acetabular abnormalities.

This is referred to as mixed cam-pincer impingement.

Epidemiology

Radiographic morphology associated with FAI is common even among people who have no hip symptoms.

Reported prevalence of cam-type morphology in asymptomatic individuals has ranged from approximately 5–57%, while pincer-type features have been reported in approximately 29–67%.

Therefore, imaging abnormalities alone do not establish symptomatic FAI.

Symptomatic Patients

Among patients undergoing surgery for symptomatic FAI, one series found approximately 47% with predominantly cam impingement, 8% with pincer impingement, and 45% with combined cam and pincer abnormalities.

Etiology

Athletic Participation

High-impact athletic activity during skeletal development may contribute to the development of cam morphology.

Sports commonly associated with repetitive hip loading include soccer, basketball, and hockey.

Pediatric Hip Disease

Residual deformity after childhood hip disorders can predispose to FAI.

A particularly important example is slipped capital femoral epiphysis (SCFE).

Other developmental abnormalities can also alter the relationship between the femoral head, neck, and acetabulum.

Trauma

Previous injury to the proximal femur or acetabulum may alter hip anatomy and result in secondary impingement.

Genetics

Genetic and developmental factors may influence proximal femoral and acetabular morphology and contribute to susceptibility.

Diagnosis

Signs and Symptoms

The typical patient reports deep groin pain, although pain may also be felt in the buttock or lateral hip.

Symptoms are often associated with activities requiring hip flexion, rotation, or prolonged sitting.

Groin Pain

Groin pain is the classic presentation.

Patients may describe a deep ache or sharp pain during squatting, running, pivoting, or sitting in a low chair.

Gluteal Pain

Some patients localize discomfort posteriorly around the gluteal region rather than directly in the groin.

Lateral Hip Pain

Pain over the greater trochanter may develop secondarily because altered hip mechanics can overload the abductor tendons or trochanteric bursa.

Pain With Hip Flexion

Patients commonly report difficulty with deep hip flexion.

Activities such as moving from standing to sitting, getting into a car, squatting, or bringing the knee toward the chest may aggravate symptoms.

Mechanical Symptoms

Clicking, catching, popping, or locking may occur.

These symptoms often suggest associated labral or chondral pathology.

Physical Examination

Hip Flexion

Hip flexion may be reduced because of pain or mechanical impingement.

Internal Rotation

Loss of internal rotation, particularly with the hip flexed, is common.

The restriction may be caused by bony morphology, pain, or both.

Resting Position

The lower extremity may rest in slight external rotation in some patients.

Provocative Tests

Anterior Impingement Test

The anterior impingement maneuver is performed by placing the hip in flexion, adduction, and internal rotation.

Reproduction of the patient’s groin or hip pain represents a positive test.

This maneuver is commonly referred to as the FADIR test.

Posterior Impingement Test

The posterior impingement test places the hip in extension and external rotation.

Reproduction of hip or groin pain suggests posterior impingement or related intra-articular pathology.

Imaging

Plain Radiographs

Plain radiographs are essential for evaluating hip morphology.

A standard assessment commonly includes an AP pelvis view together with lateral views of the proximal femur.

AP Pelvis

The AP pelvis view is used to assess acetabular coverage, joint-space preservation, femoral head shape, acetabular version, and degenerative changes.

Cross-Table Lateral View

An axial cross-table lateral radiograph can demonstrate abnormalities of the anterior femoral head-neck junction.

Frog-Leg Lateral View

A frog-leg lateral view may help identify loss of the normal femoral head-neck offset or a cam-type prominence.

False-Profile View

For a false-profile view, the patient stands with the pelvis rotated approximately 65° relative to the imaging plate.

This view is useful for assessing anterior acetabular coverage of the femoral head.

MRI

MRI can evaluate both osseous morphology and associated soft-tissue abnormalities.

It is particularly useful for identifying labral tears and articular cartilage damage.

Femoral Head-Neck Anatomy

MRI can also characterize the contour of the femoral head-neck junction and help define cam morphology.

Excluding Other Disease

MRI is useful for excluding alternative causes of hip pain, including avascular necrosis of the femoral head.

Pathological and Radiographic Findings

Cam Morphology

A cam lesion may produce a characteristic pistol-grip deformity, with loss of the normal concavity of the femoral head-neck junction and an aspherical femoral head.

Pincer Morphology

Findings suggesting pincer-type impingement include acetabular protrusio, coxa profunda, and acetabular retroversion.

Crossover Sign

On an appropriately positioned AP pelvis radiograph, acetabular retroversion may produce a crossover sign, in which the projected anterior acetabular wall crosses over the posterior wall.

Alpha Angle

The alpha angle is one method used to quantify asphericity at the femoral head-neck junction.

It is formed by a line through the center of the femoral head and neck and a second line extending from the center of the femoral head to the point where the anterior or anterolateral head-neck contour departs from the expected spherical outline.

Historically, lower thresholds such as approximately 42° have been described, although interpretation should be made in conjunction with symptoms, examination, and the imaging technique used.

Differential Diagnosis

Hip Osteoarthritis

Degenerative arthritis may produce groin pain, restricted internal rotation, and stiffness similar to FAI.

Radiographs help determine the degree of joint-space loss.

Trochanteric Bursitis

Greater trochanteric pain syndrome produces predominantly lateral hip pain and tenderness rather than classic deep groin pain.

Gluteal or Adductor Tendinopathy

Tendon disorders around the hip may reproduce pain during resisted muscle testing and should be distinguished from intra-articular impingement.

Snapping Hip Syndrome

Snapping hip may cause audible or palpable clicking during movement and can mimic the mechanical symptoms of FAI.

Acetabular Labral Tear

Labral tears frequently coexist with FAI but may also occur independently.

They commonly cause groin pain, catching, or clicking.

Juvenile Arthritis

Inflammatory arthritis should be considered in younger patients with persistent pain, stiffness, or systemic features.

Femoral Head Osteonecrosis

Avascular necrosis can cause progressive hip and groin pain and should be excluded, particularly when risk factors are present.

Athletic Pubalgia

Sports hernia or athletic pubalgia may present with groin pain in active patients and can resemble FAI clinically.

Treatment

General Principles

Treatment depends on the severity of symptoms, degree of functional impairment, associated labral or cartilage injury, and presence of established osteoarthritis.

Asymptomatic radiographic morphology alone generally does not require treatment.

Nonoperative Management

Patients with mild or moderate symptoms should usually begin with nonoperative treatment.

Conservative care can improve symptoms but does not change the underlying bony morphology.

Activity Modification

Activities that repeatedly place the hip in deep flexion, adduction, or internal rotation may need to be reduced or modified.

Examples include deep squatting, low sitting positions, or repeated pivoting activities.

Physical Therapy

Physical therapy focuses on improving hip mobility within a nonprovocative range, pelvic control, core stability, and strength of the hip musculature.

Movement patterns that repeatedly reproduce impingement should be minimized.

Anti-Inflammatory Medication

Oral NSAIDs may be used for short-term control of pain and inflammation when appropriate.

Surgery

Surgery may be considered when persistent symptoms and functional limitation continue despite an adequate trial of conservative treatment and imaging demonstrates correctable structural pathology.

Hip Arthroscopy

Hip arthroscopy is widely used to treat symptomatic FAI.

It allows treatment of both the bony abnormality and associated labral or cartilage lesions through minimally invasive portals.

Advantages

Compared with traditional open surgery, arthroscopy may be associated with less soft-tissue morbidity, faster rehabilitation, reduced postoperative pain, and fewer wound-related complications in appropriately selected patients.

Osteochondroplasty

For cam impingement, an osteochondroplasty or femoroplasty is performed.

The prominent portion of the femoral head-neck junction is resected to recreate a more normal head-neck offset.

Acetabular Rim Trimming

For pincer impingement caused by focal excessive acetabular coverage, the acetabular rim may be carefully trimmed.

The amount of resection must be controlled to avoid producing iatrogenic acetabular undercoverage or instability.

Labral Treatment

Associated acetabular labral pathology may be treated with repair or selective debridement.

When technically possible, preservation and repair of viable labral tissue are generally favored because the labrum contributes to hip stability and the fluid seal of the joint.

Open Surgical Hip Dislocation

Open surgical dislocation may be considered when deformity is too extensive or complex for arthroscopic management.

Examples include selected patients with major acetabular deformity, severe protrusio, substantial cartilage defects, or marked acetabular retroversion.

Femoral Osteotomy

A femoral osteotomy may be required when abnormal femoral version or other major structural deformity contributes to impingement and cannot be adequately corrected by simple osteochondroplasty.

Periacetabular Osteotomy

Severe acetabular malorientation may require a periacetabular osteotomy to reorient the acetabulum rather than simply trimming the rim.

This is particularly important when rim removal would worsen underlying instability or dysplasia.

Follow-Up

Prognosis

Both arthroscopic and open surgical treatment can produce substantial improvement in appropriately selected patients.

Many patients report improved function and marked reduction in pain after surgery.

Historical series have reported pain reduction approaching 95% at approximately 1 year in selected populations.

Factors Affecting Outcome

The best results generally occur in patients with limited pre-existing cartilage degeneration and preserved joint space.

Advanced osteoarthritis decreases the likelihood that impingement surgery will provide durable benefit.

Complications

Heterotopic Ossification

Ectopic bone formation may occur around the hip after surgery and can cause pain or restricted motion.

Femoral Neck Fracture

Excessive resection during femoral osteochondroplasty can weaken the femoral neck and create a risk of fracture.

Lateral Femoral Cutaneous Nerve Injury

Temporary or persistent numbness related to lateral femoral cutaneous nerve irritation may occur, particularly after procedures involving anterior hip exposure or traction.

Labral Injury

The acetabular labrum may be injured during the original disease process or during surgery.

Cartilage Injury

Articular cartilage damage may be present before treatment or can occur as a surgical complication.

Progressive chondral loss may eventually contribute to osteoarthritis.

Patient Monitoring

Follow-up should assess pain, hip range of motion, internal rotation, mechanical symptoms, gait, strength, and return to desired activities.

After surgery, monitoring should also evaluate wound healing, rehabilitation progress, heterotopic ossification, residual impingement, recurrent labral symptoms, and progression of degenerative joint disease.

Orthopaedic Surgery - Femoral Shaft Fracture in the Child

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Basics

A pediatric femoral shaft fracture involves the diaphyseal portion of the femur, generally defined as a fracture occurring more than approximately 5 cm distal to the lesser trochanter and proximal to the widened distal metaphysis.

The fracture is commonly described according to its location as proximal, midshaft, or distal.

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Mechanism

The normal femur is a strong bone and usually requires substantial force to fracture.

However, femoral shaft fractures can occur after relatively low-energy trauma in infants, toddlers, or children with structurally weakened bone.

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Prevention

Prevention includes appropriate supervision and age-appropriate safety measures.

Children with a known femoral lesion or substantial bone weakness may need to avoid high-impact or contact activities that significantly increase fracture risk.

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Epidemiology

Femoral fractures occur more commonly in areas of high population density and lower socioeconomic status.

There is a bimodal age pattern, with increased frequency in children approximately 0–3 years old and 12–16 years old.

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Pathophysiology

Different fracture configurations may suggest particular mechanisms of injury, although the fracture pattern alone does not prove how the injury occurred.

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Buckle Pattern

A buckle-type injury may suggest a direct impact.

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Spiral Fracture

A spiral fracture often reflects a rotational or twisting force.

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Transverse Fracture

A transverse pattern may result from a direct blow applied from the side.

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Comminuted or Open Fracture

A comminuted or open fracture generally suggests either very high-energy trauma or markedly weakened bone.

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Post-Fracture Overgrowth

Children commonly demonstrate approximately 1–1.5 cm of femoral overgrowth during the first 18 months after fracture healing.

This phenomenon allows a degree of initial shortening to be accepted during treatment, especially in younger children.

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Etiology by Age

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Age 0–2 Years

In infants younger than approximately 12 months, nonaccidental injury must always be considered.

Other causes include falls from a height.

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Age 2–5 Years

Common mechanisms include falls from height, falls during play, and pedestrian-versus-motor vehicle injuries.

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Age 5–16 Years

Older children and adolescents more often sustain femoral shaft fractures from bicycle accidents, pedestrian trauma, motor vehicle collisions, and sports injuries.

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Associated Conditions

Some fractures occur through abnormal bone.

Important underlying disorders include osteogenesis imperfecta, unicameral bone cyst, fibrous cortical defect or nonossifying fibroma, fibrous dysplasia, and neurologic disorders such as cerebral palsy.

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Associated Traumatic Injuries

Because many femoral shaft fractures result from significant trauma, additional injuries may occur.

These include head injury, spinal fracture, upper-extremity fracture, and other lower-extremity injuries.

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Diagnosis

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History

The history should document the mechanism, timing, and circumstances of injury.

If a pathologic fracture is suspected, the child should be asked about pain before the injury, previous fractures, or known bone disease.

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Suspected Nonaccidental Injury

When abuse is a possibility, the history should be obtained carefully from caregivers and witnesses.

Important details include the child’s position before the event, the proposed mechanism, whether that mechanism is developmentally plausible, and what occurred immediately afterward.

Any inconsistency between the history and injury pattern warrants further evaluation.

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Physical Examination

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Thigh Appearance

The thigh is usually swollen and painful.

When the fracture is displaced, the limb often appears shortened and externally rotated.

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Pain With Rotation

Internal or external rotation of the leg usually causes marked pain at the fracture site.

The limb should therefore be handled gently.

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Knee Examination

The knee may be swollen even when no ligamentous injury is present.

A more complete ligament examination can be performed after the femur has been stabilized and pain has improved.

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Neurovascular Examination

Distal pulses, capillary refill, motor function, and sensation should be documented.

Neurovascular injury is uncommon but must not be missed.

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Examination for Abuse

If nonaccidental injury is suspected, the child should be examined for additional bruises, tenderness, fractures, or other signs of trauma.

Further evaluation for occult injuries should follow child-protection protocols.

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Imaging

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Plain Radiographs

Plain radiographs are usually sufficient to establish the diagnosis.

AP and lateral views should include the entire femur and adjacent joints whenever possible.

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MRI or CT

MRI or CT may be needed when an occult nondisplaced fracture, stress fracture, or underlying lesion is suspected but plain radiographs are inconclusive.

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Skeletal Survey

When nonaccidental trauma is suspected, a skeletal survey may be indicated according to the child’s age and clinical situation.

Additional imaging may be required depending on findings.

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Diagnostic Procedures

If a malignant bone lesion is suspected, biopsy should be performed before definitive surgical treatment.

This situation is uncommon but important because inappropriate fixation through an undiagnosed tumor can complicate later oncologic management.

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Pathological Findings

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Osteogenesis Imperfecta

Thin cortices and generalized bowing may suggest osteogenesis imperfecta.

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Fibrous Dysplasia

A broad area of abnormal cortical and medullary architecture may suggest fibrous dysplasia.

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Unicameral Bone Cyst

A centrally located focal lucent lesion may be consistent with a unicameral bone cyst.

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Fibrous Cortical Defect or Nonossifying Fibroma

An eccentric cortical lesion is more typical of a fibrous cortical defect or nonossifying fibroma.

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Initial Stabilization

A displaced unstable fracture should be temporarily immobilized for comfort and to limit additional soft-tissue injury.

A traction splint or long-leg splint may be used depending on the child’s size, fracture level, and associated injuries.

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Treatment

Treatment depends primarily on age, body weight, fracture location, fracture stability, degree of comminution, associated injuries, and social circumstances.

Several methods provide excellent outcomes when used in appropriately selected patients.

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Physical Therapy

Formal physical therapy is particularly useful in children older than approximately 8–10 years.

Younger children generally regain motion and function rapidly without structured therapy.

Weight-bearing status depends on the treatment method and stage of fracture healing and should be directed by the treating orthopedic surgeon.

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Medication

Strong analgesics, including opioids, may be required during the early period after injury.

Pain generally decreases substantially after the first few weeks.

NSAID use should be individualized, particularly when there is concern about effects on fracture healing.

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Immediate Spica Casting

Immediate hip spica casting is commonly used in younger children, particularly those 6 years of age or younger and under approximately 32 kg.

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Technique

The cast extends from the trunk to the involved lower extremity and may include one or both legs.

It may be applied in the emergency department or operating room under sedation or anesthesia.

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Acceptable Alignment

In younger children, approximately 2.5 cm of shortening and 10–15° of angular deformity can often be accepted because of subsequent remodeling and femoral overgrowth.

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Healing

Union is usually achieved within approximately 6–8 weeks.

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Traction Followed by Spica Casting

Historically, children were often treated with 2–3 weeks of traction followed by application of a spica cast.

This method provides good control of length and alignment but requires prolonged hospitalization and is used much less frequently today.

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Flexible Intramedullary Nails

Flexible intramedullary nails are commonly used in children approximately 5–11 years old with appropriately located, relatively length-stable fractures.

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Limitations

They are less suitable for fractures very near the proximal or distal femur and for highly comminuted or length-unstable patterns.

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Postoperative Immobilization

Some children do not require a cast after flexible nailing.

Implants are often removed after healing, commonly several months later.

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External Fixation

External fixation is used mainly for severe open fractures, major soft-tissue injury, or selected unstable injuries.

It is typically used in children approximately 5–16 years of age.

Healing may be somewhat slower than with intramedullary fixation, and the risk of refracture after frame removal is higher.

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Plate Fixation

Plate fixation may be performed through an open or minimally invasive approach.

It is especially useful for comminuted, very proximal, very distal, or length-unstable fractures that are not ideal for flexible nails.

Plate failure is uncommon but possible.

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Rigid Intramedullary Nailing

Rigid intramedullary nails are generally reserved for older children and adolescents, commonly those older than about 10–11 years depending on size and skeletal maturity.

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Entry Point

Piriformis fossa entry should be avoided in skeletally immature patients because of the risk of injury to the femoral head blood supply and subsequent osteonecrosis.

Modern lateral trochanteric entry is preferred.

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Advantages

Rigid nails provide strong fixation and can allow earlier weight bearing in appropriately selected adolescents.

Implant removal may be considered in younger teenagers after healing.

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Follow-Up

Patients are commonly reviewed every 4–8 weeks until fracture healing is established.

Serial radiographs are usually required.

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Return to Sports

Sports and high-impact activity should be avoided until the fracture has healed adequately and strength and motion have recovered.

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Implant Removal

Flexible nails and some other implants are often removed after union.

The timing depends on implant type, symptoms, age, and surgeon preference.

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Long-Term Follow-Up

Follow-up may continue for up to approximately 2 years in younger children to monitor for overgrowth, limb-length discrepancy, or angular deformity.

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Referral for Physical Therapy

Physical therapy referral is appropriate when the child is not recovering expected range of motion, gait, or strength, or when special complications are present.

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Prognosis

Most children regain full function after treatment.

The pediatric femur has substantial healing and remodeling capacity, particularly in younger patients.

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Associated Knee Ligament Injury

Concomitant knee ligament injury can occasionally produce long-term impairment, especially in younger children.

The knee should therefore be examined both at the time of fracture stabilization and after healing, with MRI obtained if clinically indicated.

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Complications

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Nonunion

Nonunion is rare after closed pediatric femoral shaft fracture, occurring in less than approximately 1% of cases.

The rate is substantially higher in severe open fractures, historically around 10–20%.

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Malunion

Children tolerate more angular deformity than adults because of remodeling.

Approximately 15–20° of angulation may be acceptable proximally, while roughly 10° may be acceptable distally, depending on patient age and plane of deformity.

Remodeling is most reliable in children younger than approximately 10 years.

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Shortening

Up to approximately 2.5–3 cm of shortening may sometimes be accepted in younger children because subsequent overgrowth can compensate for part of the discrepancy.

Expected overgrowth is commonly around 1–1.5 cm.

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Persistent Limb-Length Discrepancy

If significant inequality remains, options such as contralateral epiphysiodesis or other limb-length procedures may be considered depending on remaining growth.

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Neurovascular Injury

Neurovascular injury is most commonly associated with open or high-energy fractures.

Femoral artery injury and thigh compartment syndrome are uncommon but serious complications.

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Infection

The risk of infection after operative treatment is low, historically around 1% in closed injuries, but rises substantially with open fractures and severe soft-tissue damage.

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Osteonecrosis

Osteonecrosis of the femoral head is a recognized complication of older-style rigid intramedullary nails inserted through the piriformis fossa.

This entry point should therefore be avoided in skeletally immature patients.

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Ligament Injury

Knee ligament injuries may coexist with the femur fracture and can be difficult to diagnose acutely.

The knee should be reassessed once the fracture is stable.

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Patient Monitoring

During the first 1–2 days, serial neurovascular examinations should be performed.

Monitoring should include distal perfusion, motor and sensory function, swelling, pain, and signs of compartment syndrome.

Subsequent visits should assess fracture alignment, callus formation, limb length, rotational alignment, knee function, and return of normal gait and activity.

Orthopaedic Surgery - Femoral Shaft Fracture in the Adult

Basics

Femoral shaft fractures involve the diaphyseal portion of the femur, extending between the proximal and distal metaphyseal regions.

In otherwise normal adult bone, they usually result from high-energy trauma, including motor vehicle collisions, falls from height, pedestrian injuries, and gunshot wounds.

In osteoporotic or pathologic bone, much lower-energy mechanisms may be sufficient to cause a fracture.

Classification

Several classification systems are used to describe femoral shaft fractures.

The Winquist and Hansen classification focuses on the amount of residual cortical contact between the major proximal and distal fragments.

Winquist and Hansen Classification

Type I fractures retain more than approximately 75% cortical contact between the principal fragments.

Type II fractures retain at least approximately 50% cortical contact.

Type III fractures have less than 50% cortical contact.

Type IV fractures have essentially no cortical contact between the main fragments.

Increasing comminution generally corresponds with increasing fracture instability.

AO/OTA Classification

The AO/Orthopaedic Trauma Association classifies femoral shaft fractures as 32A, 32B, or 32C.

Type 32A fractures are simple fractures.

Type 32B fractures contain a wedge fragment.

Type 32C fractures are complex or multifragmentary injuries.

Each group is further subdivided according to fracture morphology and severity.

Prevention

Prevention includes road and pedestrian safety measures, seat-belt and vehicle safety, fall prevention, reduction of firearm-related injury, and treatment of impending pathologic fractures before complete fracture occurs.

Epidemiology

Femoral shaft fractures demonstrate a bimodal age distribution.

They are particularly common in patients younger than approximately 25 years because of high-energy trauma and in adults older than approximately 65 years because of osteoporosis and low-energy falls.

The overall incidence has been estimated at approximately 1 per 10,000 persons per year.

Risk Factors

Young adult males are particularly represented among high-energy femoral shaft injuries.

Additional associations include urban trauma exposure and alcohol or recreational drug use.

In older adults, osteoporosis and fall risk become more important contributors.

Etiology

High-Energy Mechanisms

Common mechanisms include motor vehicle collisions, pedestrian-versus-vehicle injuries, falls from significant height, and gunshot wounds.

These mechanisms should immediately raise concern for associated multisystem trauma.

Low-Energy Mechanisms

A fall from standing height or even a twisting injury may cause a femoral shaft fracture in bone weakened by osteoporosis, metastatic disease, primary bone tumor, or another pathologic process.

Associated Injuries

A femoral shaft fracture in a trauma patient should be considered a marker for potentially severe associated injury.

The entire patient must therefore be evaluated rather than focusing only on the femur.

Ipsilateral Femoral Neck Fracture

An associated ipsilateral femoral neck fracture is uncommon but clinically important.

A substantial proportion may be missed initially, particularly in high-energy trauma.

Dedicated imaging of the femoral neck should therefore be obtained when suspicion exists.

Knee Injury

Ligamentous injury of the ipsilateral knee may accompany the fracture.

Because pain and instability are difficult to assess acutely, the knee should be re-examined after femoral stabilization.

Other Orthopaedic Injuries

Associated injuries may include pelvic fractures, spinal fractures, lower-leg trauma, foot injuries, acetabular fractures, and other fractures of the ipsilateral extremity.

Diagnosis

Signs and Symptoms

The affected thigh is usually painful, swollen, shortened, and deformed.

The patient is typically unable to bear weight.

Blood Loss

An isolated femoral shaft fracture can produce substantial internal hemorrhage into the thigh.

Average blood loss may exceed 1,200 mL, and significant blood loss can contribute to hemorrhagic shock.

Open Fracture

Approximately 5–10% of femoral shaft fractures are open injuries.

Any wound near the thigh should therefore be carefully examined for communication with the fracture.

History

Understanding the mechanism of injury is essential because it helps predict associated injuries and the likelihood of occult fractures elsewhere.

High-energy mechanisms should prompt comprehensive trauma evaluation.

Physical Examination

Trauma Survey

The examination begins with the principles of the Advanced Trauma Life Support primary survey, addressing airway, breathing, circulation, disability, and exposure before definitive management of the limb.

Life-threatening injuries take priority over the femoral fracture.

Neurovascular Examination

The neurovascular status of the entire lower extremity should be carefully examined and documented.

Distal pulses, capillary refill, motor function, and sensation should be recorded.

Hip Examination

The hip must be assessed for an associated femoral neck or acetabular injury.

Because an occult femoral neck fracture may be subtle, imaging is essential in high-energy injuries.

Knee Examination

The knee should be inspected and palpated for associated injury.

A formal ligamentous examination is best performed after the femoral fracture has been stabilized and pain is better controlled.

Laboratory Tests

Trauma and preoperative laboratory studies should be obtained according to injury severity.

These commonly include a complete blood count, metabolic panel, coagulation studies when appropriate, and blood type and cross-match.

Hematocrit and Hemoglobin

Serial hemoglobin or hematocrit measurements may be required because significant blood loss can occur into the thigh even without external hemorrhage.

Imaging

Femur Radiographs

Full-length AP and lateral radiographs of the entire femur, including the hip and knee, should be obtained.

This avoids missing associated injuries at either end of the bone.

Femoral Neck Imaging

An internal-rotation hip view or dedicated CT may be used to evaluate the ipsilateral femoral neck when an occult fracture is suspected.

Trauma Imaging

Depending on the mechanism and examination, cervical spine, chest, and pelvic imaging may also be required as part of the trauma assessment.

Contralateral Femur

Full-length radiographs of the opposite femur may be useful in highly comminuted or long-oblique fractures because they provide a reference for normal limb length and rotation.

Pathological Findings

Femoral shaft injuries commonly involve bone, surrounding muscle, and fascial tissues.

The femoral artery and sciatic nerve are rarely injured in blunt shaft fractures but may be damaged in penetrating trauma.

Pathologic Fracture

A pathologic cause should be suspected when a fracture occurs with little or no trauma, when pain was present before the fracture, or when radiographs demonstrate a destructive or permeative bone lesion.

Evaluation of Suspected Pathologic Fracture

When malignancy or another pathologic process is suspected, staging evaluation may include imaging to identify additional skeletal lesions and cross-sectional imaging of the chest, abdomen, and pelvis.

Definitive fixation should be planned only after the underlying diagnosis has been appropriately considered.

Initial Stabilization

Life-Threatening Injury

Airway, breathing, and major hemorrhage must be treated first.

Resuscitation may require intravenous fluids and blood products.

Limb Splinting

Temporary stabilization with an appropriate traction or long-leg splint can reduce pain, limit motion, and help control bleeding from the fracture.

Open Fractures

Open fractures require prompt intravenous antibiotics, sterile dressings, tetanus assessment, and urgent irrigation and debridement.

Analgesia

Adequate opioid or multimodal analgesia should be provided while monitoring respiratory and hemodynamic status.

General Treatment Principles

Most adult femoral shaft fractures are treated operatively with intramedullary nailing.

This allows reliable alignment, high union rates, and early mobilization.

Damage-Control Orthopaedics

In severely injured or physiologically unstable polytrauma patients, immediate definitive intramedullary nailing may not be appropriate.

A damage-control strategy may instead be used.

Temporary External Fixation

In patients with major hemorrhage, severe chest injury, shock, or a high systemic injury burden, the femur may initially be stabilized with external fixation.

This reduces fracture motion while limiting the additional physiologic stress of a prolonged definitive procedure.

Delayed Definitive Fixation

Once the patient has been adequately resuscitated and the initial systemic inflammatory response has stabilized, the external fixator can be exchanged for definitive fixation.

Activity Before Definitive Fixation

Before stabilization, the patient is generally restricted to bed rest.

If operative fixation must be delayed, skeletal traction may be used selectively.

Nursing Care

Pressure-Injury Prevention

Care should be taken to prevent pressure injuries involving the heels, sacrum, and buttocks, especially in patients immobilized before surgery.

Traction Pin Care

If skeletal traction is used, traction-pin sites should be monitored for skin pressure, infection, and osteomyelitis.

Physical Therapy

Rehabilitation should begin early after stabilization.

Therapy focuses on restoring hip, knee, and ankle motion, lower-extremity strength, gait, and overall mobility.

Medication

Analgesic therapy is required throughout the acute and postoperative period.

Multimodal pain control is preferred when appropriate to reduce excessive opioid use.

Surgery

External Fixation

External fixation is primarily used for damage-control stabilization in unstable polytrauma patients, severe open fractures, and fractures associated with vascular injury.

It may also be used temporarily when the soft tissues or systemic condition do not permit definitive internal fixation.

Plate Fixation

Plate fixation is rarely the first choice for a routine adult femoral shaft fracture.

It may be appropriate in selected situations, including some periprosthetic fractures with a well-fixed implant or fractures unsuitable for intramedullary nailing.

Intramedullary Nailing

Antegrade Nailing

Reamed antegrade intramedullary nailing is the standard treatment for most adult femoral shaft fractures.

The nail is inserted proximally and spans the fracture to provide load-sharing fixation.

Advantages

Intramedullary nailing provides excellent alignment and stability while preserving much of the surrounding soft-tissue blood supply.

It also permits early mobilization and, in many cases, early weight bearing.

Retrograde Intramedullary Nailing

A retrograde nail is inserted from the distal femur and advanced proximally.

It may be particularly useful in selected fracture patterns or polytrauma situations.

Indications

Potential indications include distal femoral shaft fractures, ipsilateral acetabular fractures, bilateral femoral shaft fractures, and situations in which proximal access for antegrade nailing is difficult.

It may also be useful in selected obese patients.

Ipsilateral Femoral Neck Fracture

When a femoral neck fracture is present on the same side, fixation strategy must be carefully planned because preservation and stabilization of the femoral neck are critical.

Follow-Up

Weight Bearing

Many patients can begin early weight bearing after stable intramedullary fixation, depending on fracture pattern, fixation quality, and associated injuries.

Rehabilitation

Physical therapy should emphasize gait training, restoration of hip and knee range of motion, and progressive strengthening.

Prognosis

Approximately 95% of femoral shaft fractures unite successfully without major complication when appropriately treated.

Union rates are particularly high after modern intramedullary nailing.

Complications

Pulmonary Complications

Fat embolization and pulmonary complications may occur after severe femoral trauma.

In critically injured polytrauma patients, intramedullary instrumentation can contribute to an additional inflammatory insult.

Patients with major chest or head trauma require particularly careful perioperative management.

Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome may occur as part of severe trauma, fat embolism, systemic inflammation, or pulmonary injury.

The risk is greatest in critically injured patients with multiple injuries.

Nonunion

Nonunion is relatively uncommon.

When it occurs after intramedullary nailing, exchange nailing is a commonly successful treatment.

Malunion

Rotational malalignment and limb-length discrepancy are recognized complications, particularly with highly comminuted fractures.

Rotational Deformity

Clinically important rotational malalignment may alter gait and limb mechanics.

Rotational errors greater than approximately 15° may warrant correction when symptomatic or functionally significant.

Limb-Length Discrepancy

Length differences greater than approximately 2 cm may be clinically important and should be evaluated for possible correction.

Vascular Injury

Major vascular injury is uncommon in closed femoral shaft fractures.

It is more likely after penetrating trauma or severe open injuries.

Nerve Injury

Primary sciatic or other major nerve injury is also uncommon.

However, positioning-related nerve injuries may occur during surgery.

Pudendal Nerve Palsy

Pudendal nerve palsy has been reported after prolonged pressure from the perineal post on a fracture table.

Careful padding and limiting traction time reduce this risk.

Heterotopic Ossification

Heterotopic ossification may develop around the proximal femur after antegrade nailing.

It is particularly associated with severe trauma and concomitant head injury.

Thigh Compartment Syndrome

Compartment syndrome of the thigh is uncommon but potentially limb threatening.

It can develop before or after surgery and requires urgent recognition and decompression.

Patient Monitoring

Postoperative monitoring should include repeated neurovascular examinations and assessment for increasing pain, swelling, tense compartments, or other signs of compartment syndrome.

Radiographic Follow-Up

Serial radiographs are generally obtained approximately every 6–8 weeks until clear bony union is demonstrated.

Imaging should assess alignment, callus formation, implant position, fracture healing, limb length, and evidence of hardware failure or nonunion.

Orthopaedic Surgery - Femoral Neck Fracture

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Basics

A femoral neck fracture is one of the most common injuries referred to clinically as a “broken hip.”

The femoral neck is the intracapsular portion of the proximal femur connecting the femoral head to the trochanteric region.

These fractures occur most frequently in elderly patients after relatively minor trauma, although younger patients may sustain them after high-energy injuries.

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Clinical Importance

In older adults, the consequences extend beyond the fracture itself.

Pain and immobility can lead to cardiopulmonary complications, venous thromboembolism, pressure injuries, delirium, loss of independence, substantial morbidity, and increased mortality.

Early stabilization and mobilization are therefore important goals.

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Classification

Femoral neck fractures can be broadly categorized as stable or unstable.

A stable fracture is nondisplaced and may be impacted or incomplete.

An unstable fracture is complete and displaced.

The degree of displacement strongly influences treatment and prognosis because disruption of the femoral head blood supply becomes more likely as displacement increases.

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Epidemiology

Reported incidence is approximately 27.7 per 100,000 person-years in males and 63.3 per 100,000 person-years in females.

Rates have stabilized or declined in some populations, possibly because of improved osteoporosis diagnosis and the use of antiresorptive therapy.

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Age and Sex Distribution

Among younger patients, femoral neck fractures occur more commonly in males because they are usually caused by high-energy trauma.

Among elderly patients, women are affected approximately two to three times more frequently than men, largely because of the higher prevalence of postmenopausal osteoporosis.

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Risk Factors

The most important risk factor in older adults is osteoporosis.

Any condition that increases the likelihood of falling also increases fracture risk.

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Fall-Related Risk Factors

Important contributors include unsteady gait, impaired balance, poor vision, physical inactivity, urinary urgency or incontinence, polypharmacy, syncope, sedating medications such as benzodiazepines, Parkinson disease, and other neurologic disorders.

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Demographic Risk Factors

Additional recognized risk factors include female sex after menopause and Caucasian ancestry, largely through associations with reduced bone mineral density.

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Etiology

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Younger Patients

In patients younger than approximately 50 years, femoral neck fractures usually result from high-energy trauma, such as a motor vehicle collision or significant fall.

The mechanism often involves a strong axial force transmitted along the femoral shaft.

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Older Patients

In elderly individuals, the fracture commonly occurs after low-energy trauma, particularly a fall from standing height.

Underlying osteoporosis allows relatively minor forces to produce intracapsular fracture.

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Associated Conditions

Femoral neck fractures in older adults are strongly associated with osteoporosis and medical conditions that increase fall risk.

Associated problems may include visual impairment, balance disorders, polypharmacy, Parkinson disease, syncope, urinary frequency, and other neurologic conditions.

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Diagnosis

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Signs and Symptoms

Patients usually present with severe groin or hip pain after trauma.

Patients with displaced fractures are often unable to stand or walk.

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Limb Position

With an unstable displaced fracture, the affected leg commonly appears shortened and externally rotated.

Patients may hold the hip slightly flexed because this position reduces discomfort.

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Pain With Movement

Pain worsens with attempted hip motion, particularly internal rotation.

Axial loading of the limb also reproduces pain.

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Stable Fractures

Patients with impacted or nondisplaced fractures may not demonstrate obvious shortening or external rotation.

Some may still be able to bear limited weight, which can delay diagnosis.

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History

A history of hip or thigh pain preceding the traumatic event should raise concern for an underlying pathologic process such as metastatic disease.

The clinician should also determine the mechanism of injury, preinjury ambulatory status, baseline function, osteoporosis history, and relevant medical comorbidities.

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Physical Examination

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Hip Examination

Gentle passive range of motion should be assessed.

Pain with internal rotation is particularly common.

Forceful examination should be avoided when fracture is strongly suspected.

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Limb Alignment

Displaced fractures typically produce shortening and external rotation of the affected leg.

This deformity may be absent in stable fractures.

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Pelvic Examination

The pelvis should be palpated and assessed radiographically when appropriate to exclude a concomitant pelvic fracture.

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Straight-Leg Raise

An active straight-leg raise typically produces significant hip or groin pain and may be impossible.

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Neurovascular Examination

Distal motor, sensory, and vascular function should be documented, particularly after high-energy trauma.

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Laboratory Evaluation

Patients being admitted for operative treatment generally undergo routine preoperative laboratory testing.

This commonly includes a complete blood count, metabolic studies, coagulation testing when indicated, and blood type and screen.

Additional studies depend on age and medical status.

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Cardiopulmonary Assessment

Older adults may require an electrocardiogram, chest imaging when clinically indicated, and prompt medical evaluation to optimize perioperative status without unnecessarily delaying surgery.

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Imaging

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Plain Radiographs

Initial imaging should include an AP pelvis radiograph and dedicated AP and cross-table lateral views of the affected hip.

The entire femur should also be imaged when the mechanism suggests associated injury.

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Occult Femoral Neck Fracture

If radiographs are negative but clinical suspicion remains high, an occult nondisplaced fracture should be assumed until excluded.

MRI is the most sensitive imaging study for detecting an occult femoral neck fracture.

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CT

Dedicated CT can be helpful when MRI is unavailable or when more detailed bony definition is needed.

CT is particularly useful in patients with an ipsilateral femoral shaft fracture, in whom a femoral neck fracture may be subtle or missed.

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Pathological Findings

In elderly patients, especially those with osteoporosis, the fracture may be comminuted.

Comminution is particularly common in the subcapital region.

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Differential Diagnosis

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Occult Femoral Neck Fracture

An occult nondisplaced fracture should remain a major consideration in any patient with post-traumatic hip pain and normal initial radiographs.

MRI is often diagnostic.

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Pelvic Fracture

Pelvic fractures can produce groin pain and inability to bear weight and should be considered after falls or high-energy trauma.

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Intertrochanteric Fracture

Intertrochanteric fractures occur extracapsularly and may produce a similar clinical appearance.

Radiographs usually distinguish them from femoral neck fractures.

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Infection

Septic arthritis or osteomyelitis may cause severe hip pain and inability to bear weight, especially when no clear traumatic event is present.

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Greater Trochanteric Pain

Greater trochanteric bursitis or other lateral hip disorders may produce pain but generally do not cause the severe functional loss associated with a displaced fracture.

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Metastatic Disease

Pathologic fracture through metastatic bone should be considered when pain preceded the injury or imaging demonstrates an abnormal underlying lesion.

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Treatment

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General Principles

Treatment depends on patient age and physiologic status, fracture displacement, bone quality, preinjury function, fracture pattern, and associated medical conditions.

The goals are to restore mobility, reduce complications of immobility, and either preserve the native femoral head or replace it when preservation is unlikely to succeed.

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Stable Femoral Neck Fracture

Stable nondisplaced fractures are generally treated with internal fixation, commonly using multiple cannulated screws.

The objective is to prevent displacement while preserving the patient’s native femoral head.

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Displaced Fracture in Younger Patients

In younger, active patients, particularly those younger than approximately 50 years, a displaced femoral neck fracture should be treated urgently with anatomic reduction and internal fixation.

The reduction may be performed by closed or open techniques.

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Importance of Urgent Treatment

Femoral head preservation is particularly important in young patients.

Because the blood supply to the femoral head may be compromised by displacement, these injuries are considered orthopaedic emergencies or urgent injuries, with emphasis on prompt reduction and stable fixation.

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Polytrauma

In multiply injured patients, treatment of the femoral neck fracture must be coordinated with management of associated life-threatening injuries.

Trauma, anesthesia, and other surgical teams may need to participate simultaneously.

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Older Patients

In older patients with displaced fractures, particularly those of advanced physiologic age or with limited functional demand, arthroplasty is generally favored over internal fixation because of the high risks of nonunion and osteonecrosis.

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Patients Favoring Arthroplasty

Arthroplasty may be particularly appropriate in older sedentary patients or those with conditions such as Parkinson disease, hemiplegia, or severe pre-existing joint disease.

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Medical Optimization

Prompt medical assessment is essential in elderly patients.

Necessary medical problems should be corrected rapidly, but excessive delay in surgery increases the risks associated with prolonged immobilization.

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Activity

Before surgery, the patient is generally maintained at bed rest with protected positioning.

Routine traction is not usually beneficial for pain control and may cause skin complications.

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Nursing Care

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Pressure-Injury Prevention

Older immobilized patients are at risk for pressure ulcers involving the sacrum, buttocks, and heels.

Frequent repositioning, heel protection, pressure-relieving surfaces, and careful skin monitoring are important.

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Delirium Prevention

Postoperative and hospital-associated delirium is common in older adults.

Preventive measures include frequent reorientation, visible clocks and calendars, preservation of sleep-wake cycles, early mobilization, correction of sensory impairment, and avoidance of unnecessary deliriogenic medications.

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Physical Therapy

Physical therapy should begin as early as medically appropriate, usually on the first postoperative day.

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Older Patients

Most elderly patients are encouraged to bear weight as tolerated after fracture fixation or arthroplasty when the construct permits.

Early mobilization decreases the complications of prolonged bed rest.

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Younger Patients

Young patients treated with internal fixation may require restricted weight bearing until adequate fracture healing has occurred.

The exact duration depends on fracture stability and fixation.

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Medication

Analgesia is required throughout the acute and postoperative period.

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Opioid Considerations in Older Adults

Narcotic analgesics may cause delirium, respiratory depression, sedation, nausea, and constipation in elderly patients.

Pain control should therefore be adequate but carefully monitored.

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Younger Patients

Younger patients with high-energy fractures often require sufficient analgesia to permit safe rehabilitation and participation in therapy.

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Surgery

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Positioning and Imaging

Internal fixation may be performed with the patient supine on a fracture table under fluoroscopic guidance.

Alternative positioning on a radiolucent table may also be used depending on the surgical approach and fracture pattern.

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Cannulated Screw Fixation

In young patients and in stable nondisplaced fractures, fixation frequently consists of three cannulated screws placed across the femoral neck into the femoral head.

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Screw Configuration

The screws are typically distributed in a triangular configuration to maximize stability.

They should obtain secure purchase within the subchondral bone of the femoral head while avoiding joint penetration.

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Importance of Reduction

Precise reduction is critical.

Poor alignment increases the risk of mechanical failure, nonunion, and loss of femoral head viability.

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Basicervical Fractures

Fractures occurring near the base of the femoral neck, closer to the trochanters, have different mechanical characteristics and may require a sliding hip screw and side plate or another fixed-angle construct rather than isolated cannulated screws.

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Ipsilateral Femoral Shaft Fracture

Approximately 6–9% of patients with femoral shaft fractures may also have an ipsilateral femoral neck fracture.

Careful imaging is therefore required.

When both injuries are present, stabilization of the femoral neck generally receives priority because a missed or displaced neck fracture can have severe consequences.

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Arthroplasty

Prosthetic replacement may be performed through lateral, anterolateral, or posterior surgical approaches depending on surgeon preference and patient factors.

Both cemented and uncemented femoral components may be used.

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Hemiarthroplasty

Hemiarthroplasty replaces the femoral head and neck while preserving the native acetabulum.

It is commonly chosen for older, lower-demand patients with displaced fractures and without significant pre-existing acetabular disease.

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Total Hip Arthroplasty

Total hip arthroplasty replaces both the femoral and acetabular sides of the joint.

It may be favored in active older adults with good preinjury function or patients with significant pre-existing hip osteoarthritis.

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Follow-Up

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Prognosis

Femoral neck fracture in the elderly is associated with substantial morbidity and mortality.

Historical 30-day mortality rates have ranged from approximately 4–31%, depending on patient age, medical comorbidity, preinjury function, and treatment setting.

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Period of Highest Risk

Mortality is greatest during the first several months after fracture, particularly in medically frail patients or those who remain immobilized for prolonged periods.

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Younger Patients

Young patients generally have better overall survival but remain at significant risk for femoral head osteonecrosis, nonunion, and later reconstructive surgery.

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Complications

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Osteonecrosis

Osteonecrosis of the femoral head is one of the most important complications after displaced intracapsular fracture.

It results from compromise of the femoral head blood supply.

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Nonunion

Failure of the fracture to unite is particularly concerning in displaced fractures treated with internal fixation.

Revision fixation or arthroplasty may eventually be required.

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Malunion

Healing in poor alignment can alter hip biomechanics and produce persistent pain, shortening, or functional impairment.

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Prosthetic Dislocation

Hip arthroplasty carries a risk of postoperative dislocation.

Risk varies according to surgical approach, implant design, patient factors, and soft-tissue stability.

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Prosthetic Loosening

Long-term aseptic loosening or wear can occur after arthroplasty.

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Infection

Deep or superficial surgical infection can complicate either internal fixation or arthroplasty.

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Persistent Pain

Persistent pain may result from nonunion, osteonecrosis, implant problems, soft-tissue dysfunction, arthritis, or infection.

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Cardiopulmonary Complications

Older immobilized patients are at risk for pneumonia, cardiac complications, pulmonary embolism, and deconditioning.

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Postoperative Delirium

Delirium is a frequent complication in elderly patients, particularly those with pre-existing cognitive impairment or multiple medical problems.

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Venous Thromboembolism

Deep venous thrombosis and pulmonary embolism are important postoperative risks.

Appropriate thromboprophylaxis should be provided unless contraindicated.

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Patient Monitoring

Patients with substantial medical comorbidity or multiple traumatic injuries may require intensive cardiovascular and respiratory monitoring throughout the perioperative period.

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Follow-Up After Internal Fixation

Patients treated with internal fixation should undergo serial radiographs until union is established.

Imaging should assess fracture alignment, fixation stability, healing, collapse, and evidence of osteonecrosis.

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Follow-Up After Arthroplasty

Patients treated with arthroplasty require clinical and radiographic surveillance to assess implant position, dislocation, loosening, infection, and recovery of mobility.

Follow-up intervals vary according to surgeon preference and patient factors.

Orthopaedic Surgery - Femoral Anteversion

Basics

Femoral torsion describes the rotational relationship between the axis of the femoral neck and the transcondylar axis of the distal femur.

When the femoral neck is rotated excessively anteriorly relative to the distal femur, the condition is termed increased femoral anteversion.

Increased anteversion commonly produces in-toeing during walking or running.

In most children, the condition is benign and improves spontaneously as growth occurs.

Synonym

In-toeing caused by femoral anteversion is sometimes referred to colloquially as pigeon-toed gait, although this term can also describe other causes of in-toeing.

Epidemiology

In-toeing from increased femoral anteversion often becomes increasingly apparent during the first several years of childhood, commonly reaching its greatest visibility around 4–5 years of age.

Thereafter, spontaneous improvement usually occurs, with substantial correction by approximately 8 years of age.

Sex and Symmetry

Increased femoral anteversion is typically bilateral and relatively symmetric.

Females, on average, demonstrate somewhat greater femoral internal rotation and femoral version than males.

Incidence

Increased femoral anteversion is one of the most common causes of in-toeing in early childhood.

Risk Factors

A positive family history of rotational abnormalities increases the likelihood that a child will demonstrate increased femoral anteversion.

Etiology

Normal Development

Many newborns have substantial femoral anteversion together with an external rotation contracture of the hip and internal tibial torsion.

The external rotation contracture can initially conceal the increased femoral anteversion, so the in-toeing may not become obvious until later in childhood.

Anteversion at Birth

Femoral anteversion is approximately 40° at birth.

With normal growth and remodeling, it progressively decreases.

Adult Values

By approximately 8 years of age, much of the remodeling has occurred, with femoral anteversion approaching the typical adult range of approximately 10–15°.

Some additional variation persists among individuals.

Genetic and Connective-Tissue Factors

Differences in inheritance, connective-tissue characteristics, and skeletal development contribute to the variation in femoral rotation seen among children.

Femoral Version and Torsion

The terminology can vary.

Femoral version generally refers to the rotational orientation of the femoral neck relative to the distal femur, while femoral torsion may be used to describe rotational contribution from the femoral shaft.

The term total femoral version recognizes that both proximal and shaft anatomy contribute to the overall rotational alignment.

Associated Conditions

Increased femoral anteversion may coexist with internal tibial torsion.

The overall direction of the foot during gait reflects the combined rotational contributions of the femur, tibia, and foot.

Diagnosis

Signs and Symptoms

The characteristic presentation is in-toeing during walking or running, often accompanied by an appearance of the knees and patellae turning inward.

Most affected children have no pain.

W-Sitting

Children with increased anteversion often prefer to sit in the W position, with the hips internally rotated and the knees flexed while the feet lie outside the hips.

This position is comfortable because of their increased internal hip rotation.

Parental Concerns

Parents commonly seek evaluation because of frequent tripping, falling, unusual shoe wear, or concern about the appearance of the child’s gait.

These concerns are often most noticeable during running.

Knee Pain

Pain is uncommon in isolated childhood femoral anteversion.

Anterior knee pain may occasionally occur when excessive femoral anteversion is combined with external tibial torsion and patellofemoral malalignment, sometimes termed miserable malalignment syndrome.

History

Birth History

A birth and developmental history should be obtained.

This is particularly important when abnormal muscle tone, delayed milestones, or gait abnormalities raise concern for an underlying neurologic disorder such as cerebral palsy.

Family History

The family history should include rotational deformities, skeletal dysplasias, metabolic bone disorders such as rickets, and significant childhood gait abnormalities.

Physical Examination

General Principles

The diagnosis can usually be established clinically without advanced imaging.

Examination should begin with gait observation and then proceed systematically from the hips to the feet.

Gait

During walking, affected children demonstrate in-toeing with the patellae often pointing medially.

This helps distinguish femoral anteversion from isolated tibial or foot abnormalities.

Running Pattern

During running, the legs may demonstrate a characteristic circumduction or “eggbeater” appearance, reflecting excessive internal femoral rotation.

Rotational Profile

A complete rotational profile should be recorded when evaluating pediatric in-toeing.

This helps determine whether the deformity arises from the femur, tibia, foot, or a combination of levels.

Foot Progression Angle

The foot progression angle describes the angle between the long axis of the foot and an imaginary straight line representing the direction of walking.

A negative or inward angle reflects in-toeing, while an outward angle indicates out-toeing.

Hip Rotation

Passive internal and external rotation of the hip is an important clinical estimate of femoral rotational alignment.

The child is commonly examined prone with the knees flexed to 90°.

Hip Rotation in Infants

In infants, average internal rotation is approximately 40°, with a broad normal range of roughly 10–60°.

Average external rotation is about 70°, with a range of approximately 45–90°.

Hip Rotation by Age 10

By around 10 years of age, internal rotation averages approximately 50°, while external rotation averages about 45°, although substantial individual variation remains.

Increased Internal Rotation

Markedly increased internal rotation combined with reduced external rotation supports increased femoral anteversion.

Internal rotation approaching 70°, 80°, or 90° may correspond clinically to mild, moderate, or severe rotational excess.

External Rotation

Increased anteversion is typically associated with decreased external hip rotation.

The asymmetry between internal and external rotation is often more useful than any isolated number.

Accuracy of Clinical Examination

Clinical hip rotation measurements provide a useful estimate of femoral anteversion and correlate reasonably well with CT-based rotational measurements in many patients.

Tibial Torsion Assessment

Thigh-Foot Axis

The thigh-foot axis is measured with the patient prone and the knees flexed.

It is the angle between the longitudinal axis of the thigh and the axis of the foot.

This measurement primarily reflects tibial rotational alignment.

Transmalleolar Axis

The transmalleolar axis compares a line connecting the medial and lateral malleoli with the distal femoral condylar axis.

It provides another estimate of tibial torsion.

Foot Assessment

Heel-Bisector Line

The heel-bisector line is used to evaluate forefoot alignment.

A line is projected from the center of the heel through the forefoot to determine the presence of metatarsus adductus or abduction.

Definition of Abnormal Rotation

A rotational measurement approximately two standard deviations outside the normal mean for age is generally considered abnormal.

Clinical significance, however, depends on symptoms and functional impairment rather than measurement alone.

Imaging

General Role

Routine imaging is unnecessary for most children with typical symmetric femoral anteversion and a normal neurologic and hip examination.

Indications for Radiographs

Radiographs should be considered when there is marked asymmetry, significant pain, short stature, progressive deformity, or an unusually abnormal rotational profile.

Pelvic Radiographs

A pelvic radiograph is appropriate when the hip examination is abnormal or when developmental dysplasia of the hip or another structural hip disorder is suspected.

CT

CT can quantify femoral version accurately and may be useful in patients being considered for corrective surgery.

Because of radiation exposure, it is not routinely required for uncomplicated childhood in-toeing.

Concerning Findings

A progressive, highly asymmetric, or painful rotational deformity should prompt evaluation for underlying pathology rather than being assumed to represent physiologic femoral anteversion.

Cerebral Palsy

A gait combining equinus and in-toeing, particularly when accompanied by abnormal tone, weakness, or delayed development, may suggest cerebral palsy.

Developmental Dysplasia of the Hip

A Trendelenburg gait, restricted hip movement, limb-length inequality, or other abnormal hip findings should raise concern for developmental dysplasia of the hip.

Differential Diagnosis

Internal Tibial Torsion

Internal tibial torsion is another common cause of childhood in-toeing.

Unlike femoral anteversion, the patellae may face forward while the feet turn inward.

Developmental Dysplasia of the Hip

DDH can alter lower-extremity rotation and gait and should be excluded when the hip examination is abnormal.

Cerebral Palsy

Neuromuscular rotational abnormalities may mimic idiopathic anteversion but are usually accompanied by abnormal tone, weakness, contracture, or other neurologic findings.

Metatarsus Adductus

Forefoot adduction can also produce in-toeing and is identified through examination of the foot and heel-bisector line.

Treatment

General Principles

Most children require no active treatment because femoral anteversion improves naturally with growth.

Education and reassurance are the mainstays of management.

Natural Remodeling

Substantial spontaneous remodeling occurs before approximately 8 years of age.

After this point, further rotational correction is usually limited.

Observation

Children with a typical, symmetric deformity and no significant functional impairment can be observed.

The appearance may remain noticeable for several years even while gradual improvement is occurring.

Bracing and Shoe Modifications

Special shoes, braces, twister cables, and similar devices do not alter the natural history of femoral anteversion and are generally unnecessary.

Activity

Routine activity should not be restricted.

Most children can participate fully in sports and normal play.

Physical Therapy

Exercises and stretching do not change the underlying femoral rotation.

Physical therapy is therefore not required solely to correct idiopathic anteversion.

Therapy may be useful when another associated condition produces weakness, balance problems, or abnormal movement patterns.

Persistent Femoral Anteversion

Some children retain increased anteversion beyond 8 years of age.

Most remain asymptomatic and do not require treatment even when the rotational profile remains outside average values.

Indications for Surgery

Corrective surgery is rarely necessary.

It may be considered in a child older than approximately 8 years who has severe persistent anteversion, substantial functional impairment, and a deformity that is unlikely to remodel further.

Functional Indications

Potential indications include recurrent tripping or falling that interferes with sports or activities of daily living, marked gait dysfunction, or persistent pain clearly related to the rotational deformity.

Cosmetic appearance alone is usually insufficient.

Degree of Anteversion

Femoral anteversion greater than approximately 50° has historically been used as one factor supporting surgery when significant symptoms are also present.

The rotational measurement should never be used in isolation.

Miserable Malalignment Syndrome

Surgery may also be considered in carefully selected patients with excessive femoral anteversion combined with external tibial torsion, increased Q-angle, patella alta, and persistent anterior knee pain.

This combination is sometimes referred to as miserable malalignment syndrome.

Surgery

Femoral Derotation Osteotomy

The definitive surgical treatment is a femoral derotation osteotomy.

The femur is divided, rotated into more appropriate alignment, and stabilized with internal fixation.

Osteotomy Level

The osteotomy may be performed at the proximal femur, diaphysis, or distal femur.

No single level is ideal for every patient because excessive rotation may arise from different portions of the femur.

Preoperative planning should therefore be individualized.

Intramedullary Fixation

A diaphyseal derotation osteotomy can be stabilized with an intramedullary nail.

In adolescents, this approach can provide reliable rotational correction and may improve function and pain in carefully selected symptomatic patients.

Weight Bearing

Depending on fixation stability and surgeon preference, patients may be allowed to bear weight relatively early, sometimes as tolerated.

Combined Femoral and Tibial Osteotomy

Patients with miserable malalignment syndrome may require both femoral and tibial derotation osteotomies when clinically significant abnormalities exist at both levels.

Follow-Up

Prognosis

The prognosis is excellent.

Most children experience substantial spontaneous improvement by approximately 8 years of age and have no long-term functional limitation.

Arthritis Risk

Isolated increased femoral anteversion in otherwise healthy children has not been clearly associated with an increased risk of hip or knee osteoarthritis.

Rotational alignment at the opposite extreme, particularly decreased femoral anteversion or excessive retroversion in some settings, may have different biomechanical consequences.

Surgical Complications

Potential complications of femoral derotation osteotomy include nonunion, malunion, hardware prominence, infection, overcorrection, undercorrection, and persistence of pain or functional symptoms.

Careful patient selection is therefore essential.

Patient Monitoring

Children with mild typical femoral anteversion generally need only routine observation.

Those with severe deformity may be reviewed annually or every 6–12 months to document expected rotational improvement with growth.

Follow-up should assess gait, hip rotation, foot progression angle, functional symptoms, symmetry, pain, and the development of any findings suggesting an underlying neurologic or structural disorder.