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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.
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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.
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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.
⸻
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.
⸻
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.
⸻
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.
⸻
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.
⸻
Nursing Care
⸻
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.
⸻
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.
⸻
Physical Therapy
Physical therapy should begin as early as medically appropriate, usually on the first postoperative day.
⸻
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.
⸻
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.
⸻
Medication
Analgesia is required throughout the acute and postoperative period.
⸻
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.
⸻
Younger Patients
Younger patients with high-energy fractures often require sufficient analgesia to permit safe rehabilitation and participation in therapy.
⸻
Surgery
⸻
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.
⸻
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.
⸻
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.
⸻
Importance of Reduction
Precise reduction is critical.
Poor alignment increases the risk of mechanical failure, nonunion, and loss of femoral head viability.
⸻
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.
⸻
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.
⸻
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.
⸻
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.
⸻
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.
⸻
Follow-Up
⸻
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.
⸻
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.
⸻
Younger Patients
Young patients generally have better overall survival but remain at significant risk for femoral head osteonecrosis, nonunion, and later reconstructive surgery.
⸻
Complications
⸻
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.
⸻
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.
⸻
Malunion
Healing in poor alignment can alter hip biomechanics and produce persistent pain, shortening, or functional impairment.
⸻
Prosthetic Dislocation
Hip arthroplasty carries a risk of postoperative dislocation.
Risk varies according to surgical approach, implant design, patient factors, and soft-tissue stability.
⸻
Prosthetic Loosening
Long-term aseptic loosening or wear can occur after arthroplasty.
⸻
Infection
Deep or superficial surgical infection can complicate either internal fixation or arthroplasty.
⸻
Persistent Pain
Persistent pain may result from nonunion, osteonecrosis, implant problems, soft-tissue dysfunction, arthritis, or infection.
⸻
Cardiopulmonary Complications
Older immobilized patients are at risk for pneumonia, cardiac complications, pulmonary embolism, and deconditioning.
⸻
Postoperative Delirium
Delirium is a frequent complication in elderly patients, particularly those with pre-existing cognitive impairment or multiple medical problems.
⸻
Venous Thromboembolism
Deep venous thrombosis and pulmonary embolism are important postoperative risks.
Appropriate thromboprophylaxis should be provided unless contraindicated.
⸻
Patient Monitoring
Patients with substantial medical comorbidity or multiple traumatic injuries may require intensive cardiovascular and respiratory monitoring throughout the perioperative period.
⸻
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.
⸻
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.
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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.
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Orthopaedic Surgery - The Female Athlete Triad
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Basics
The female athlete triad is a clinical spectrum involving three interrelated abnormalities: low energy availability, menstrual dysfunction, and impaired bone health with reduced bone mineral density (BMD).
Low energy availability may occur with or without a formal eating disorder, and an athlete does not need to demonstrate all three components simultaneously to be at risk of clinically important or potentially irreversible skeletal consequences.
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Components of the Triad
The three major components are menstrual dysfunction, inadequate energy availability relative to exercise expenditure, and decreased bone mineral density.
Each exists along a continuum of severity, and abnormalities in one component can adversely influence the others.
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Menstrual Dysfunction
Menstrual dysfunction is common in affected athletes, with amenorrhea being the classic presentation.
Menstrual abnormalities result largely from hypothalamic suppression caused by inadequate energy availability and subsequent disturbances of reproductive hormone production.
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Low Energy Availability
Low energy availability occurs when dietary energy intake is insufficient to support both the demands of exercise and the body’s normal physiologic functions.
This may result from an eating disorder such as anorexia nervosa or bulimia nervosa, deliberate dietary restriction, extreme dieting, or simply inadequate caloric intake for the athlete’s training load.
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Bone Mineral Density
Reduced energy availability and menstrual dysfunction interfere with normal bone remodeling.
Hypoestrogenism is an important contributor to increased bone resorption, although multiple other metabolic and endocrine abnormalities also affect bone health.
⸻
Importance of Screening
Athletes at risk may have any body habitus and may participate in any sport.
Therefore, screening should not be restricted to athletes who appear underweight or participate only in traditionally high-risk sports.
⸻
Incomplete Triad
All three components do not have to be present for adverse effects to occur.
For example, an athlete may already experience reduced bone formation and stress injury while still having intermittent or apparently normal menstrual cycles.
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Opportunities for Screening
Screening can occur in multiple clinical settings, including primary care, obstetrics and gynecology, pediatric care, sports medicine, and orthopedic clinics.
Preparticipation examinations and preventive health visits provide particularly useful opportunities.
⸻
Epidemiology
The full triad has historically been estimated to occur in approximately 2–5% of the general female population, while individual components are considerably more common.
The prevalence is substantially higher in certain athletic populations.
⸻
High-Risk Sports
Sports emphasizing leanness, low body weight, endurance, or aesthetic appearance are associated with increased risk.
Examples include distance running, gymnastics, ballet and other forms of dance.
⸻
Weight-Class Sports
Athletes participating in sports with formal weight categories are also vulnerable because of pressure to reduce body mass.
Examples include boxing, wrestling, and mixed martial arts.
⸻
Associated Conditions and Complications
The three components of the triad interact with each other, and each can produce additional medical complications.
Persistent energy deficiency is the central driver in many affected athletes.
⸻
Menstrual Dysfunction and Reproductive Health
Chronic menstrual dysfunction may impair reproductive function and can contribute to infertility.
Restoration of adequate energy availability often plays a central role in normalizing hypothalamic and reproductive function.
⸻
Stress Fractures
Stress fractures are among the most clinically important orthopedic complications.
Athletes with the triad have a substantially increased risk of bone stress injury, historically reported at approximately two to four times that of unaffected individuals.
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High-Risk Stress Fracture Sites
Important high-risk locations include the femoral neck, anterior tibial cortex, tarsal navicular, base of the fifth metatarsal, and sesamoids of the first metatarsal.
These sites have greater risks of delayed union, nonunion, displacement, or complete fracture.
⸻
Peak Bone Mass
Adolescence and early adulthood are critical periods for achieving peak bone mass.
Low energy availability and hypoestrogenism during these years may prevent optimal skeletal mineral accumulation and contribute to osteopenia, osteoporosis, and increased fracture susceptibility later in life.
⸻
Hypothalamic Suppression
Low energy availability suppresses normal hypothalamic function.
This alters gonadotropin-releasing hormone signaling and produces multiple downstream endocrine abnormalities.
⸻
Hypoestrogenism and Hypoleptinemia
Reduced estrogen and leptin levels are among the hormonal consequences of persistent energy deficiency.
Both can adversely affect bone metabolism and other organ systems.
⸻
Brain-Bone Interaction
Energy deficiency produces complex feedback changes between the central nervous system, endocrine system, and skeleton.
Unless adequate energy availability is restored, these alterations may perpetuate impaired bone formation and abnormal remodeling.
⸻
Diagnosis
⸻
General Principles
Diagnosis depends on recognizing one or more elements of the triad and determining whether inadequate energy availability is contributing.
A detailed history of menstrual function, nutrition, exercise, body image, previous fractures, and weight change is essential.
⸻
Signs and Symptoms
⸻
Stress Fractures
Recurrent or unusual stress fractures should prompt evaluation for the female athlete triad, particularly when they involve high-risk locations or occur after relatively modest training changes.
⸻
Amenorrhea
Amenorrhea may be classified as primary or secondary.
⸻
Primary Amenorrhea
Primary amenorrhea is traditionally defined as absence of menarche by approximately 15 years of age despite otherwise appropriate development of secondary sexual characteristics.
Delayed pubertal development requires broader endocrine evaluation.
⸻
Secondary Amenorrhea
Secondary amenorrhea refers to absence of menstrual periods for more than approximately 3 months in someone who previously menstruated regularly, although the precise definition depends on the patient’s prior cycle pattern.
⸻
Weight and Body Habitus
Marked thinness may be present but is not required.
Athletes with apparently normal weight or body composition can still have significant energy deficiency.
⸻
Eating Disorder History
A history of anorexia nervosa, bulimia nervosa, restrictive eating, recurrent purging, or substantial concern about weight and body image should increase suspicion.
⸻
Restrictive Diets
Experimentation with extreme or highly restrictive dietary regimens may result in inadequate caloric, protein, calcium, vitamin D, or micronutrient intake.
⸻
Fatigue
Severe or persistent fatigue may reflect chronic under-fueling, anemia, endocrine disturbance, excessive training, or other consequences of low energy availability.
⸻
Screening
⸻
Preventive Visits
Important opportunities for screening include preparticipation sports examinations, annual preventive visits, gynecologic examinations, and visits for musculoskeletal injury.
⸻
Screening Questions
Screening should explore body weight changes, menstrual history, dietary intake, body image, training volume, previous stress fractures, exercise habits, and relevant sexual and reproductive history.
⸻
Screening Tools
Several organizations have developed screening recommendations and questionnaires, including sports medicine, pediatric, and collegiate athletic organizations.
The goal is early recognition before irreversible skeletal consequences develop.
⸻
Physical Examination
⸻
Vital Signs and Anthropometrics
Height, weight, pulse, blood pressure, and other vital signs should be recorded at each relevant visit.
Trends over time may be more informative than a single measurement.
⸻
Musculoskeletal Examination
A thorough musculoskeletal examination should be performed, especially when the athlete reports focal pain.
Localized bony tenderness at a high-risk stress fracture site requires careful evaluation.
⸻
Signs of Hormonal or Nutritional Dysfunction
Possible examination findings include dry skin, hair loss, signs of estrogen deficiency, and delayed development of secondary sexual characteristics.
These findings may indicate significant endocrine or nutritional disturbance.
⸻
Laboratory Tests
⸻
Pregnancy Testing
Pregnancy must be excluded in any reproductive-age athlete presenting with amenorrhea.
A beta-human chorionic gonadotropin test is therefore an important initial investigation.
⸻
Gonadotropins
Follicle-stimulating hormone may be measured to help distinguish hypothalamic suppression from primary ovarian dysfunction.
Depending on the clinical setting, luteinizing hormone may also be assessed.
⸻
Thyroid Function
Thyroid-stimulating hormone should be measured because thyroid disease can cause menstrual disturbance and systemic symptoms that resemble components of the triad.
⸻
Prolactin
Serum prolactin should be considered during evaluation of amenorrhea because hyperprolactinemia can suppress reproductive function.
⸻
Estradiol
Estradiol measurement may provide evidence of hypoestrogenism.
Results should be interpreted in conjunction with menstrual history and other endocrine studies.
⸻
Progesterone Challenge
A progesterone withdrawal challenge has historically been used in selected patients to assess estrogen status and outflow tract function, although its role depends on the broader gynecologic evaluation.
⸻
CBC and Metabolic Studies
A complete blood count and comprehensive metabolic panel may help identify anemia, electrolyte abnormalities, nutritional deficiencies, or systemic complications of disordered eating.
Additional laboratory testing should be guided by history and examination.
⸻
Imaging
⸻
Dual-Energy X-Ray Absorptiometry
Dual-energy X-ray absorptiometry (DXA or DEXA) is used to evaluate bone mineral density when reduced bone mass is suspected.
The lumbar spine and hip are commonly assessed.
⸻
Interpretation in Younger Patients
In premenopausal women and adolescents, Z-scores rather than T-scores are generally emphasized because bone density is compared with age-matched controls.
Bone-density results must also be interpreted in the context of clinical risk factors and fracture history.
⸻
Low Bone Mineral Density
A Z-score between approximately −1 and −1.9 in the presence of relevant clinical risk factors may indicate clinically important low BMD in an athlete.
A Z-score of −2.0 or lower is particularly concerning and warrants comprehensive evaluation.
⸻
Plain Radiographs
AP and lateral radiographs may be obtained when focal bone tenderness raises concern for stress fracture.
Early stress injuries may not be visible on radiographs.
⸻
MRI
MRI is the preferred advanced imaging modality for suspected extremity stress fractures because of its excellent sensitivity and specificity.
It can detect bone stress reactions before a visible fracture line develops.
⸻
Comparison With Other Modalities
MRI generally provides more useful information for bone stress injury than nuclear scintigraphy, CT, or ultrasound in most clinical settings.
⸻
Differential Diagnosis
⸻
Hypothalamic Disorders
Amenorrhea may result from hypothalamic disorders unrelated to athletic energy deficiency.
Important considerations include Kallmann syndrome, anorexia nervosa, severe systemic stress, and medication-related suppression.
⸻
Pituitary Disorders
Pituitary causes include prolactinoma, Sheehan syndrome, infiltrative disease such as sarcoidosis, and other pituitary dysfunction.
⸻
Ovarian Disorders
Potential ovarian causes include polycystic ovary syndrome, primary ovarian insufficiency, and Turner syndrome.
⸻
Endocrine Disorders
Other endocrine diseases, including Cushing syndrome and thyroid disorders, can affect menstruation, body composition, and bone health.
⸻
Treatment
⸻
General Principles
Management is complex and requires correction of the underlying energy deficit, treatment of menstrual and skeletal consequences, and management of any associated eating disorder or psychological condition.
A multidisciplinary strategy is often most effective.
⸻
Multidisciplinary Care
The treatment team may include a sports medicine physician, primary-care clinician, dietitian, mental-health professional, gynecologist or endocrinologist, athletic trainer, and orthopedic specialist when bone stress injury is present.
⸻
Nutritional Rehabilitation
The cornerstone of treatment is restoration of adequate energy availability.
This generally requires increasing caloric intake, decreasing excessive exercise expenditure when necessary, or both.
⸻
Nutritional Quality
Dietary counseling should emphasize adequate intake of protein, calcium, vitamin D, carbohydrates, fats, and micronutrients, rather than focusing solely on total calories.
⸻
Psychological Treatment
Psychological counseling is important when body-image disturbance, disordered eating, anxiety, depression, or compulsive exercise is present.
⸻
Cognitive Behavioral Therapy
Cognitive behavioral therapy can help address maladaptive beliefs and behaviors surrounding food, body weight, and exercise.
⸻
Hormonal Therapy
The primary treatment of functional hypothalamic menstrual disturbance is correction of energy deficiency.
Hormonal therapy may be considered in selected patients when menstrual dysfunction or impaired bone health persists despite nutritional rehabilitation.
⸻
Combined Oral Contraceptives
Estrogen-containing oral contraceptives can produce withdrawal bleeding, but they may mask persistent hypothalamic dysfunction and are not a substitute for restoring adequate energy availability.
They should not be relied upon as the primary strategy for improving bone density in energy-deficient athletes.
⸻
Transdermal Estrogen
Physiologic transdermal estrogen replacement may be considered in selected patients with persistent hypoestrogenism and low bone density after adequate nutritional intervention, usually with specialist involvement.
⸻
Calcium and Vitamin D
Adequate calcium and vitamin D intake should be ensured.
A commonly cited target for premenopausal adults is approximately 1,000 mg of calcium and 600 IU of vitamin D daily, although requirements may vary according to age, dietary intake, vitamin D status, and clinical circumstances.
⸻
Medication
⸻
SSRIs
Selective serotonin reuptake inhibitors may be useful when depression, anxiety, or certain eating-disorder-related psychiatric symptoms coexist.
They do not correct low energy availability itself.
⸻
Bisphosphonates
Bisphosphonates are generally used very cautiously in young women because of their long skeletal retention and reproductive considerations.
They may be considered only in unusual severe cases under specialist supervision rather than as routine treatment for the triad.
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Stress Fracture Treatment
Most stress injuries are treated initially with activity modification, protection from impact loading, correction of nutritional and hormonal abnormalities, and gradual return to activity after healing.
Management depends strongly on fracture site and risk of progression.
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Surgery
Surgery may be required when a stress fracture fails appropriate nonoperative treatment or when the fracture occurs at a high-risk location with substantial potential for delayed healing, displacement, or nonunion.
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High-Risk Stress Fractures
Sites traditionally considered high risk include the femoral neck, anterior tibial cortex, medial malleolus, patella, tarsal navicular, and base of the fifth metatarsal.
The exact need for fixation depends on fracture orientation, displacement, symptoms, and athletic demands.
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Follow-Up
⸻
Team Communication
Close communication among members of the multidisciplinary team is essential.
Nutritional, psychological, menstrual, and orthopedic issues should be managed together rather than independently.
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Clinical Monitoring
Follow-up should assess energy intake, body weight trends, menstrual recovery, psychological health, training volume, pain, stress injuries, and return-to-sport readiness.
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Repeat Laboratory Studies
Laboratory studies may be repeated as needed to assess improvement in endocrine, nutritional, or metabolic abnormalities.
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Repeat Bone Density Testing
DXA may be repeated periodically when clinically indicated.
In persistent or severe cases, reassessment at approximately yearly intervals may be appropriate because meaningful changes in bone density occur slowly.
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Prognosis
Outcome depends heavily on early recognition and restoration of adequate energy availability.
Menstrual function and many metabolic abnormalities may recover with treatment, but loss of peak bone mass during adolescence may not be completely reversible.
This makes early screening particularly important.
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Complications
Potential complications include recurrent stress fractures, delayed or incomplete bone healing, low peak bone mass, osteopenia or osteoporosis, reproductive dysfunction, chronic fatigue, and psychological consequences of disordered eating.
Severe energy deficiency may also affect cardiovascular, gastrointestinal, immune, and endocrine function.
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Patient Monitoring
Long-term monitoring should continue until energy availability is adequate, menstrual function is stable, bone stress injuries have healed, and skeletal health is improving.
Athletes should return to unrestricted sport progressively, with decisions based on medical stability, nutritional recovery, bone health, and risk of recurrent injury.
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Orthopaedic Surgery - Extensor Tendon Laceration
Basics
Extensor tendon lacerations are relatively common because the extensor tendons lie superficially along the dorsum of the hand and wrist, making them vulnerable to direct injury.
Disruption of an extensor tendon often produces an immediate change in the resting posture of the involved finger or hand.
Functional Consequences
The specific deformity depends on the level of injury.
A distal injury near the distal interphalangeal (DIP) joint may produce a mallet-type posture, while an injury involving the extensor mechanism over the proximal interphalangeal (PIP) joint may lead to a boutonniere pattern.
Extensor tendon injuries may impair active extension of the fingers, thumb, or wrist.
Typical Patient Population
These injuries occur most commonly in young adults.
Males are affected more frequently than females.
Classification
Extensor tendon lacerations are generally classified as partial or complete, based on the amount of tendon disruption identified during examination or wound exploration.
Timing of Repair
Many complete extensor tendon lacerations require operative repair.
Repair may be performed in the emergency department or operating room depending on the level and complexity of injury.
Because the extensor mechanism has relatively limited retraction and is not constrained within a pulley system like the flexor tendons, repair can often still be performed successfully within approximately 2 weeks of injury.
Epidemiology
Extensor tendon lacerations are less common overall than flexor tendon injuries.
Etiology
The usual mechanism is a sharp laceration over the dorsal hand, finger, or wrist.
The superficial position of the extensor tendons makes them particularly susceptible to knives, glass, machinery, and other penetrating injuries.
Fight-Bite Injury
A laceration over the dorsal metacarpophalangeal joint may result from striking another person’s teeth.
This so-called fight bite is particularly important because the tendon, joint capsule, and MCP joint may be contaminated with oral flora.
Associated Conditions
Extensor tendon injuries may occur together with open fractures, open joints, retained foreign bodies, or traumatic arthrotomy.
These associated injuries may substantially alter management.
Diagnosis
Signs and Symptoms
A dorsal laceration may reveal the tendon ends directly within the wound, sometimes with only minimal exploration.
A change in finger posture or loss of active extension should raise immediate concern for tendon disruption.
Loss of Active Extension
The patient may be unable to actively extend one or more joints distal to the level of injury.
The pattern of weakness helps localize the injured tendon segment.
Mallet Deformity
An injury involving the terminal extensor tendon at the DIP joint causes inability to actively extend the distal phalanx.
The fingertip therefore rests in flexion, producing a mallet deformity.
Boutonniere Deformity
Disruption of the central slip over the PIP joint may eventually produce a boutonniere deformity, characterized by PIP flexion with DIP extension or hyperextension.
This deformity may not always be immediately apparent after injury.
Independent Extensor Tendons
The index and small fingers possess additional independent extensor tendons.
A partial injury may therefore produce only subtle loss of extension strength or range of motion rather than complete inability to extend.
Physical Examination
General Examination
All fingers should be examined individually for active extension.
The wrist should also be assessed for range of motion and extension strength.
Neurologic Examination
A complete neurologic examination should be performed before administration of local anesthetic.
This helps document any associated nerve injury.
Local Anesthetic Block
After the neurologic examination, a local field block can be useful to reduce pain and allow a more reliable assessment of active tendon function.
Pain alone can otherwise limit motion and mimic tendon disruption.
Extrinsic Extensor Testing
One useful method is to place the patient’s palm flat on a table and ask the patient to lift each finger individually away from the surface.
Failure to elevate a specific digit suggests loss of its extrinsic extensor function.
Wound Exploration
The wound should be carefully inspected for partial or complete tendon disruption.
Exploration should also assess for contamination, foreign material, joint penetration, and associated fracture.
Laboratory Tests
Routine laboratory studies are not required for diagnosis.
If operative management is planned, standard preoperative testing may be obtained according to the patient’s age, comorbidities, and anesthetic requirements.
Imaging
Plain Radiographs
AP and lateral radiographs should be obtained when there is concern for an associated fracture, dislocation, or retained foreign body.
Radiographs are particularly important in high-energy trauma or fight-bite injuries.
Differential Diagnosis
Extensor Avulsion Injury
An avulsion injury of the extensor mechanism may cause the same functional deficit as a tendon laceration.
For example, a bony avulsion at the DIP joint can produce a mallet deformity without a sharp tendon transection.
Fracture
A fracture involving the dorsal aspect of the phalanx or metacarpal can also impair active extension and should be excluded radiographically.
Treatment
General Principles
Treatment priorities include wound care, prevention of infection, restoration of tendon continuity when necessary, and protection of the repair during healing.
Management depends on the location, depth, contamination, and completeness of the tendon injury.
Tetanus Prophylaxis
Tetanus immunization status should be reviewed.
A booster or tetanus toxoid should be administered when indicated.
Antibiotics
Antibiotics may be required for contaminated wounds, open fractures, open joints, or bite injuries.
The choice of antibiotic should reflect the likely organisms and mechanism of injury.
Fight-bite wounds require coverage for human oral flora rather than routine skin flora alone.
Irrigation and Debridement
Contaminated wounds should undergo thorough irrigation and debridement.
Devitalized tissue and foreign material should be removed.
Temporary Skin Closure
The skin may be temporarily closed when appropriate until definitive tendon repair is performed.
Grossly contaminated wounds may require delayed closure.
Splinting
The injured hand or finger is generally splinted in extension or a protected position to reduce tendon separation and prevent further injury.
Specialist Referral
Orthopaedic or hand-surgery consultation is appropriate for complete tendon lacerations, complex wounds, associated fracture or joint injury, and uncertain tendon function.
Physical Therapy and Hand Therapy
Rehabilitation depends on the anatomic zone of injury, tendon involved, repair technique, and associated injuries.
The goal is to protect tendon healing while minimizing stiffness, adhesions, and loss of function.
Early Motion
When the repair is sufficiently strong, carefully controlled passive and active motion may be introduced early.
Modern rehabilitation protocols attempt to balance tendon protection with prevention of adhesions.
Surgery
Tendon Repair
For a complete laceration requiring repair, the tendon ends are identified, mobilized, approximated, and sutured.
Nonabsorbable sutures such as 4-0 polypropylene or braided polyester have traditionally been used, with the exact repair technique depending on tendon level and thickness.
Suture Technique
Mattress-type or other core suture configurations may be used to obtain secure approximation of the tendon ends.
The repair should restore appropriate tendon length and alignment without excessive tension.
Proximal Injuries
Lacerations at the level of the wrist or more proximally are usually repaired in the operating room because multiple tendons may be involved and exposure is more extensive.
Comparison With Flexor Tendon Repair
Extensor tendon repair is generally less technically demanding than flexor tendon repair at the same level.
Extensor tendons are not surrounded by a tight pulley system, and postoperative gliding stresses are often lower.
Delayed Repair
Because of this anatomy, definitive repair can sometimes be delayed for up to approximately 2 weeks without a substantial adverse effect on outcome, provided the wound and tendon remain suitable for reconstruction.
Postoperative Splinting
Protective splinting is required after repair while the tendon heals.
The exact splint position and duration depend on the zone of injury and rehabilitation protocol.
Follow-Up
Prognosis
The prognosis is generally good after complete and appropriately performed repair, particularly when the injury is isolated and rehabilitation is well supervised.
Factors Affecting Outcome
Outcome is influenced by the level of injury, wound contamination, associated fracture or joint injury, adequacy of repair, scar formation, and adherence to postoperative therapy.
Complications
Infection
Infection can occur, especially in contaminated wounds, open joints, and bite injuries.
Fight-bite injuries are particularly high risk.
Open Joint Injury
A laceration that penetrates the joint can lead to septic arthritis if not recognized and treated appropriately.
Repair Failure
The tendon repair may rupture if it is overloaded before adequate healing occurs.
Scarring
Scar formation may limit tendon glide and contribute to stiffness or cosmetic changes.
Adhesions
Adhesions between the repaired tendon and surrounding tissue may restrict excursion and reduce active extension.
Loss of Function
Persistent extension lag, stiffness, weakness, or deformity may remain if healing is incomplete or rehabilitation is inadequate.
Patient Monitoring
Follow-up should assess wound healing, infection, tendon integrity, active extension, passive motion, scar formation, and adherence to splinting and therapy.
Serial examination is important to detect early repair failure, progressive stiffness, or adhesions so that rehabilitation can be adjusted promptly.
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Orthopaedic Surgery - Ewing Sarcoma
Basics
Ewing sarcoma is a high-grade malignant small round-cell tumor that most commonly arises in bone during childhood and adolescence.
It frequently affects the long bones, pelvis, and spine, with the diaphysis or metadiaphysis of long bones being characteristic locations.
Bone pain is the most common presenting symptom.
Systemic Features
Unlike many other primary bone tumors, Ewing sarcoma may produce systemic manifestations.
Patients may develop fever, malaise, weight loss, leukocytosis, and an elevated erythrocyte sedimentation rate, sometimes creating a clinical picture that resembles infection.
Spinal Disease
When the tumor involves the spine, patients may develop nerve-root irritation, radicular symptoms, or neurologic dysfunction from local extension.
Classification
Ewing sarcoma has traditionally been staged using the Musculoskeletal Tumor Society, or Enneking, staging system.
Because Ewing sarcoma is considered a high-grade malignancy, localized lesions are frequently classified as high-grade tumors, and many extend beyond the original bone compartment.
Metastatic Disease at Presentation
Approximately 20–25% of patients may have detectable metastatic disease at diagnosis.
The lungs and other bones are the most common metastatic sites.
Synonym
Ewing sarcoma has historically been categorized among the small round-cell sarcomas.
Epidemiology
Frequency
Ewing sarcoma is the second most common primary malignant bone tumor of childhood, after osteosarcoma.
Age
The disease occurs predominantly in children, adolescents, and young adults.
Most patients are younger than 25 years, while occurrence in children younger than 3 years is uncommon.
Sex
Males are affected somewhat more frequently than females.
Ethnic Distribution
Ewing sarcoma is considerably more common in individuals of European ancestry and is rare in many non-Caucasian populations.
Genetics
A characteristic molecular abnormality is a reciprocal chromosomal translocation, most commonly t(11;22)(q24;q12).
This rearrangement produces an EWSR1-FLI1 fusion gene, which encodes an abnormal transcription factor involved in tumor development.
Other Molecular Rearrangements
Less common EWSR1-related fusion partners can occur, but EWSR1-FLI1 is the classic and most frequent abnormality.
Molecular testing is useful in confirming the diagnosis when the histologic appearance is uncertain.
Etiology
The exact cause of Ewing sarcoma is unknown.
There is no established environmental exposure or inherited syndrome responsible for most cases.
The characteristic chromosomal rearrangement is acquired within the tumor cells rather than usually being inherited.
Diagnosis
Signs and Symptoms
The typical patient presents with localized bone pain and tenderness that have been present for several weeks or months.
Symptoms may initially be attributed to a sports injury or musculoskeletal strain.
Soft-Tissue Mass
As the tumor enlarges and extends beyond the cortex, a palpable soft-tissue mass may develop.
The mass may be firm, tender, and associated with local warmth or swelling.
Constitutional Symptoms
Some patients develop fever, fatigue, malaise, anorexia, or weight loss.
These symptoms, together with elevated inflammatory markers, can make Ewing sarcoma difficult to distinguish initially from osteomyelitis.
Pathologic Fracture
Occasionally, the tumor weakens the involved bone sufficiently to produce a pathologic fracture.
Physical Examination
Early Disease
The physical examination may be relatively normal during the early stages.
Pain can precede a palpable mass or visible swelling.
Advanced Local Disease
As the soft-tissue component enlarges, the examiner may identify swelling, tenderness, warmth, or a palpable mass over the involved bone.
Neurologic Examination
Patients with spinal or pelvic tumors should undergo careful neurologic examination because nerve roots, the spinal cord, or major peripheral nerves may be affected by local extension.
Laboratory Tests
Complete Blood Count
A complete blood count should be obtained.
Leukocytosis may occur, although it is nonspecific.
ESR and Other Studies
The erythrocyte sedimentation rate may be elevated.
Electrolytes and general baseline laboratory studies are also obtained before systemic therapy.
Bone Marrow Evaluation
Bone marrow aspiration and biopsy have historically been included in staging because marrow involvement may occur.
Their use depends on contemporary staging protocols and the presence of other evidence suggesting disseminated disease.
Biopsy
Tissue diagnosis is mandatory before definitive treatment.
When the tumor has a substantial soft-tissue component, biopsy can often be performed through the extraosseous portion, avoiding unnecessary penetration of additional uninvolved bone.
Biopsy should be carefully planned with the orthopedic oncology team so that the biopsy tract can be removed during definitive resection.
Imaging
Plain Radiographs
Plain radiographs are essential for initial evaluation.
They commonly demonstrate an aggressive lytic lesion arising in the diaphysis or metadiaphysis, although appearances vary.
The fibula is one of the characteristic long-bone sites.
Bone Destruction
Radiographs may show a large region of permeative or destructive bone loss.
The margins are often poorly defined, reflecting aggressive tumor growth.
Reactive Bone Formation
Variable amounts of reactive new bone may be present.
This can create a mixed lytic and sclerotic appearance.
Periosteal Reaction
A characteristic feature is a layered periosteal reaction sometimes described as an “onion-skin” appearance.
Other aggressive periosteal patterns may also occur.
Soft-Tissue Extension
The tumor commonly extends through the cortex into adjacent soft tissue.
A large soft-tissue mass may be present despite relatively modest radiographic bone destruction.
Early Radiographs
Very early disease may occasionally be subtle or even appear relatively normal on plain radiographs.
Persistent unexplained bone pain therefore warrants further evaluation when clinical concern remains high.
MRI
MRI is the most important modality for defining the local extent of the primary tumor.
It demonstrates medullary involvement, soft-tissue extension, neurovascular relationships, adjacent joint involvement, and the longitudinal extent of disease.
MRI is also essential for surgical planning.
Chest Imaging
Because the lung is a common site of metastasis, staging includes chest imaging.
Chest CT is more sensitive than plain chest radiography for detecting pulmonary metastases.
Skeletal Staging
Whole-body skeletal imaging is performed to search for bone metastases.
Historically, technetium bone scintigraphy has been used, although current staging may incorporate additional whole-body imaging according to institutional protocols.
Pathological Findings
Small Round Blue Cells
Histologically, Ewing sarcoma consists of numerous small, round, relatively uniform malignant cells that stain deeply blue on hematoxylin and eosin preparations.
Cellular Appearance
The cells are densely packed and contain scant cytoplasm.
Cell borders may be indistinct, giving the microscopic field a somewhat blurred or “out-of-focus” appearance.
Immunohistochemistry
Immunohistochemical staining is used to support the diagnosis.
Strong membranous expression of CD99 is characteristic but not completely specific.
Molecular demonstration of an EWSR1-related fusion provides additional diagnostic confirmation.
Differential Diagnosis
Osteomyelitis
Ewing sarcoma is most commonly confused clinically with osteomyelitis.
Both can present with pain, fever, elevated inflammatory markers, and an aggressive-appearing bone lesion.
Biopsy is often necessary when the distinction is uncertain.
Neuroblastoma
Metastatic neuroblastoma can mimic Ewing sarcoma histologically, particularly in children younger than 5 years.
Age, clinical context, immunohistochemical staining, and molecular testing help distinguish the two.
Lymphoma
Primary or secondary lymphoma involving bone may also resemble Ewing sarcoma.
This is especially important in younger children.
Appropriate lymphoid markers help establish the diagnosis.
Rhabdomyosarcoma
Rhabdomyosarcoma is another small round-cell malignancy that may enter the differential diagnosis.
Muscle-specific markers such as desmin and myogenic regulatory proteins help distinguish it.
Eosinophilic Granuloma
Langerhans cell histiocytosis, particularly eosinophilic granuloma, may produce a destructive bone lesion and should be considered in children and young adults.
Metastatic Disease
In adults, particularly those older than approximately 30 years, metastatic carcinoma and other secondary malignancies should also be considered.
Treatment
General Principles
Treatment requires multimodal therapy.
Systemic chemotherapy is essential because Ewing sarcoma is regarded as a systemic disease even when metastases are not detectable at diagnosis.
Local control is achieved with surgery, radiotherapy, or a combination of both.
Chemotherapy
Multiagent chemotherapy is a central component of treatment.
Specific agents and treatment schedules vary according to current pediatric or adult oncology protocols.
The goals are to treat micrometastatic disease, shrink the primary tumor, and reduce the risk of recurrence.
Radiotherapy
Ewing sarcoma is relatively radiosensitive.
External-beam radiotherapy may be used as definitive local treatment when surgery would cause unacceptable morbidity, or it may be combined with surgery when margins are inadequate or local control remains uncertain.
Radiation Planning
The treatment field must encompass the involved tumor volume while protecting surrounding normal structures as much as possible.
Long-term radiation effects are especially important in children.
Surgery
Role of Surgery
Surgery has become an important method of obtaining local control whenever the tumor can be removed safely with an acceptable functional result.
Surgical Margin
When resection is performed, the objective is a wide surgical margin with complete removal of the tumor.
Limb Salvage
Limb-salvage surgery is possible in the great majority of extremity cases.
Amputation is now uncommon and is reserved for selected unresectable or severely complicated lesions.
Expendable Bones
Wide resection is particularly suitable when the tumor involves relatively expendable bones such as the fibula, iliac wing, or clavicle, where removal may produce less functional loss.
Physical Therapy
Physical therapy is used during and after treatment to maintain joint range of motion, muscle strength, mobility, and functional independence.
Rehabilitation requirements vary substantially according to tumor location and the reconstructive procedure performed.
Follow-Up
Prognosis
Modern multimodal treatment has substantially improved survival.
Historical series report approximately 60–70% 5-year survival for patients treated with contemporary chemotherapy and local control, with outcomes being best for localized disease.
Adverse Prognostic Sites
Tumors arising in the pelvis or spine generally have a less favorable prognosis than tumors of the extremities.
This relates partly to larger tumor size, difficulty obtaining wide surgical margins, and proximity to critical structures.
Metastatic Disease
Patients presenting with metastases have a substantially worse prognosis than those with localized tumors.
Pulmonary-only metastases generally carry a better prognosis than widespread bone or bone-marrow metastases.
Complications
Radiation-Associated Sarcoma
A secondary sarcoma may rarely arise within a previous radiation field several years after treatment.
Historical rates of post-radiation sarcoma have been approximately 2–4% in some series.
Pathologic or Treatment-Related Fracture
Fracture may occur in irradiated or surgically reconstructed bone.
The proximal femur is particularly vulnerable after treatment involving this region.
Osteonecrosis
Patients treated for pelvic or proximal femoral tumors may develop osteonecrosis of the femoral head, particularly after radiation or extensive local therapy.
Functional Impairment
Muscle weakness, joint stiffness, growth disturbance, limb-length discrepancy, and gait abnormalities may develop following surgery or radiation in skeletally immature patients.
Metastatic Surveillance
Pulmonary Metastases
The lungs are a common site of recurrence.
Historically, chest CT has been obtained every 3–4 months for the first 2–3 years, then approximately every 6 months until 5 years, with less frequent long-term surveillance thereafter.
The exact schedule should follow the treating oncology protocol.
Bone Metastases
Bone metastases have traditionally been monitored using radionuclide bone scanning or other whole-body imaging.
Surveillance is most intensive during the first several years after treatment, when recurrence risk is greatest.
Local Recurrence
Local recurrence may occur despite therapy.
Historical rates have been approximately 10–30% after chemotherapy combined with radiation and lower, around 5–10%, after chemotherapy combined with complete surgical resection, although rates vary substantially according to tumor site, stage, and margin status.
Imaging for Local Recurrence
MRI or CT can be used to evaluate the primary site when no large metallic prosthesis interferes with imaging.
In patients with reconstructive implants, surveillance may rely more heavily on plain radiographs, physical examination, and appropriately selected cross-sectional imaging.
Patient Monitoring
Follow-up should include surveillance for local recurrence, pulmonary metastases, skeletal metastases, treatment toxicity, secondary malignancy, growth disturbance, fracture, and functional impairment.
The first several years after treatment require the most intensive surveillance because the risk of recurrence is highest during this period.
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Orthopaedic Surgery - Eosinophilic Granuloma
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Basics
Eosinophilic granuloma is the osseous manifestation of Langerhans cell histiocytosis (LCH) and is the most common skeletal presentation of this disease spectrum.
LCH is now regarded as a clonal disorder of Langerhans-type cells rather than a group of entirely separate diseases.
Bone involvement may occur as a solitary lesion, as multifocal skeletal disease without visceral involvement, or as multisystem disease involving bone together with other organs.
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Sites of Involvement
Commonly affected bones include the skull, ribs, pelvis, vertebral column, mandible, and diaphyses of long bones.
However, virtually any bone can be involved.
A single skeletal lesion is more common than multifocal bone disease.
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Historical Classification of LCH
Historically, LCH was divided into three separate clinical entities: eosinophilic granuloma, Hand–Schüller–Christian disease, and Letterer–Siwe disease.
These names are now largely considered historical descriptions along a spectrum of LCH severity.
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Eosinophilic Granuloma
The term eosinophilic granuloma traditionally referred to a localized or solitary skeletal lesion without significant visceral disease.
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Hand–Schüller–Christian Disease
This historical term described multifocal skeletal involvement with systemic disease affecting organs such as the skin, lymph nodes, liver, or spleen.
The classic but uncommon triad consists of lytic skull lesions, exophthalmos, and diabetes insipidus.
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Letterer–Siwe Disease
Letterer–Siwe disease was the historical name for an aggressive multisystem form occurring predominantly in very young children, particularly those younger than 2 years.
Features may include lymphadenopathy, hepatosplenomegaly, skin involvement, and pulmonary disease, and the condition can be life-threatening.
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Synonyms
Older terminology includes histiocytosis X and reticuloendotheliosis.
The preferred current term is Langerhans cell histiocytosis.
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Epidemiology
LCH is rare.
Skeletal disease is seen most frequently in patients younger than 30 years, with peak presentation commonly between approximately 5 and 10 years of age.
Males are affected more often than females, with a reported ratio of approximately 2:1.
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Etiology
The precise initiating cause is not fully understood.
LCH is characterized by abnormal accumulation and proliferation of pathologic Langerhans-type cells, accompanied by a prominent inflammatory response.
This process can cause focal bone resorption and lytic destruction.
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Diagnosis
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General Principles
Diagnosis is based on the combination of clinical presentation, imaging, and histopathologic confirmation when required.
Because eosinophilic granuloma may mimic infection or malignancy, biopsy is often necessary unless the clinical and radiographic appearance is highly characteristic.
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Spinal LCH
A characteristic spinal presentation may include vertebral body collapse, preservation of the adjacent intervertebral disc spaces, and absence of a significant paraspinal soft-tissue mass.
This pattern is highly suggestive of LCH.
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Percutaneous Biopsy
Percutaneous needle biopsy is an effective means of establishing the diagnosis in uncertain lesions and can often avoid a larger open procedure.
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Signs and Symptoms
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Pain
Localized bone pain is one of the most common symptoms.
Pain may be gradual or relatively acute and is generally centered over the involved bone.
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Swelling and Tenderness
The lesion may produce localized swelling, tenderness, and warmth.
These inflammatory features can cause the condition to resemble osteomyelitis.
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Fever
Low-grade fever may occasionally be present, particularly with more active or multifocal disease.
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Physical Examination
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Skeletal Examination
The skull and accessible skeleton should be palpated for tender areas, swelling, or palpable bony defects.
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Orbital Involvement
Orbital lesions may occur, often in the superolateral orbit.
Patients may develop a visible mass, proptosis, ptosis, erythema, or visual disturbance, and the appearance can sometimes be mistaken for infection.
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Spine Examination
The spine should be inspected and gently percussed for focal tenderness.
Any evidence of deformity or neurologic abnormality should prompt further assessment.
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Gait
The patient’s gait should be observed for limping or reluctance to bear weight, particularly when the pelvis or lower extremity is involved.
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Laboratory Tests
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Inflammatory Markers
The erythrocyte sedimentation rate may be elevated, although the finding is nonspecific.
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Peripheral Eosinophilia
Peripheral eosinophilia may occur but is neither required nor diagnostic.
Normal laboratory results do not exclude LCH.
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Imaging
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Plain Radiographs
Radiographs commonly demonstrate well-defined, sharply marginated lytic lesions, often described as “punched-out.”
The appearance varies according to location and stage of healing.
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Healing Response
As the lesion heals, a rim of reactive or sclerotic bone may form along the periphery.
This represents reparative bone formation.
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Cortical Changes
The lesion may produce endosteal scalloping, cortical destruction, expansion, or periosteal reaction.
Because the cortex may be eroded unevenly from within, some skull lesions develop a characteristic beveled or “hole-within-a-hole” appearance.
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Skull Lesions
Calvarial lesions are classically sharply defined and lytic.
Asymmetric destruction of the inner and outer tables may produce a beveled-edge appearance.
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Vertebra Plana
In the spine, severe collapse of the vertebral body may produce vertebra plana, in which the vertebral body becomes a thin, flattened wafer of bone.
The adjacent disc spaces are usually preserved.
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Mandibular and Maxillary Lesions
In the jaws, loss of supporting alveolar bone may make the teeth appear suspended within the lesion.
This produces the classic “floating tooth” appearance.
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Bone Scan
Bone scintigraphy is not the most reliable screening study because some LCH lesions may demonstrate little or no increased tracer uptake.
A negative bone scan therefore does not exclude disease.
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Pathological Findings
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Langerhans Cells
Histologically, the lesion contains sheets of abnormal Langerhans cells with abundant pale cytoplasm.
The nuclei often demonstrate longitudinal grooves, producing a characteristic coffee-bean appearance.
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Immunohistochemistry
Langerhans cells characteristically express CD1a and S-100, and contemporary diagnosis also commonly uses langerin, or CD207.
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Inflammatory Background
The abnormal cells are surrounded by a mixed inflammatory infiltrate.
Eosinophils are often prominent, although lymphocytes, neutrophils, macrophages, and multinucleated giant cells may also be present.
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Differential Diagnosis
⸻
Ewing Sarcoma
Ewing sarcoma may present with bone pain, fever, and an aggressive lytic lesion.
Clinical and imaging overlap may be substantial, making biopsy necessary in suspicious cases.
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Lymphoma
Primary lymphoma of bone can produce pain and a destructive lesion and should be considered, particularly when the radiographic appearance is atypical.
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Osteomyelitis
Osteomyelitis is one of the most important mimics because both conditions may present with pain, warmth, fever, elevated inflammatory markers, and bone destruction.
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Great Imitator
Eosinophilic granuloma has historically been called a “great imitator” because its clinical and radiographic features may resemble both infection and neoplasm.
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Treatment
⸻
General Principles
Many solitary bone lesions are self-limiting and may heal spontaneously.
Treatment therefore depends on symptoms, anatomic location, structural risk, and whether multisystem disease is present.
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Observation
Observation is appropriate for selected patients with a characteristic solitary lesion, mild symptoms, and no impending fracture or danger to a joint surface.
Serial radiographs are used to confirm healing.
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Curettage
Curettage may be performed when the diagnosis is uncertain, symptoms are persistent, or the lesion is structurally significant.
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Bone Grafting
Bone grafting may be added after curettage if a large defect remains or if mechanical support is required.
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Steroid Injection
Intralesional corticosteroid injection has been used successfully for selected solitary lesions.
Methylprednisolone acetate is one commonly used agent and may promote symptom resolution and bone healing.
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Impending Pathologic Fracture
If the lesion significantly weakens the bone and a pathologic fracture appears imminent, operative curettage with bone grafting, with or without fixation, may be required.
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Articular Surface at Risk
Lesions threatening a joint surface may also warrant surgical treatment to prevent collapse or structural damage.
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Treatment of Multifocal or Systemic Disease
Patients with multiple skeletal lesions or visceral involvement require assessment by a multidisciplinary team.
Systemic treatment may be necessary, with therapy tailored to the extent of disease and organs involved.
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Chemotherapy
Historically, agents such as corticosteroids, methotrexate, and doxorubicin have been used in multisystem disease.
Modern systemic treatment depends on disease extent, risk-organ involvement, age, and current hematology-oncology protocols.
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Vertebra Plana
Vertebral collapse caused by LCH often has a favorable natural history in children.
The lesion may heal spontaneously, and partial restoration of vertebral body height can occur over time.
Neurologic compromise is uncommon when there is no epidural extension or instability.
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Surgery
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General Role
Surgery is unnecessary in most uncomplicated solitary lesions.
Its role is primarily diagnostic or mechanical rather than oncologic.
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Indications
Operative treatment may be considered when there is failure of nonoperative management, diagnostic uncertainty, impending pathologic fracture, substantial structural weakness, articular involvement, or neurologic compression.
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Curettage and Fixation
Curettage with bone grafting and internal fixation may be used when the involved bone is at substantial risk of fracture or has already fractured in an unstable pattern.
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Follow-Up
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Prognosis
The prognosis for isolated skeletal LCH is generally excellent.
Many lesions resolve with observation or limited treatment.
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Pathologic Fracture
Pathologic fractures can occur through weakened bone.
These fractures generally heal well with appropriate nonoperative or surgical treatment.
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Patient Monitoring
When the diagnosis is secure and there is no structural danger, the lesion can be followed with serial plain radiographs until healing is evident, often over several months.
Clinical follow-up should assess pain, swelling, function, skeletal stability, and development of new lesions or systemic symptoms.
Persistent pain, progressive destruction, new masses, neurologic findings, or evidence of multisystem disease should prompt reassessment and specialist referral.
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Orthopaedic Surgery - Enchondroma
Basics
An enchondroma is a common benign cartilaginous tumor composed of mature hyaline cartilage within the medullary canal, usually arising in the metaphysis or metadiaphysis of bone.
It most frequently involves the small tubular bones of the hands and feet, particularly the proximal phalanges.
Enchondromas may also occur in the distal femur, proximal humerus, and tibia but are uncommon in the spine, pelvis, and ribs.
They do not arise in bones formed entirely by membranous ossification.
Growth Pattern
A typical enchondroma is a nongrowing or very slowly changing lesion once skeletal maturity is reached.
Cartilage growth usually ceases in adulthood, although progressive mineralization may make the lesion appear radiographically different over time.
Malignant Potential
Small peripheral appendicular lesions are generally benign.
Large cartilaginous tumors arising in the axial skeleton carry a greater concern for malignant behavior and require more careful evaluation.
Epidemiology
Enchondroma is one of the most common benign bone tumors.
It is the most common bone tumor involving the small bones of the hands and feet and represents the most common destructive-appearing lesion encountered in the hand.
Age and Sex
Enchondromas can occur at any age but are recognized more frequently in adults.
In children, many lesions remain radiographically occult because the cartilaginous matrix has not yet mineralized.
Males and females are affected approximately equally.
Etiology
The exact origin is uncertain.
One proposed mechanism is persistence of epiphyseal growth cartilage that fails to remodel normally and remains within the metaphysis.
Another possibility is persistence of part of the original cartilaginous anlage of the developing bone.
Associated Conditions
Enchondroma Protuberans
Enchondroma protuberans is an unusual eccentric variant in which the cartilaginous lesion causes focal cortical bulging or outward extension.
Enchondromatosis
Enchondromatosis describes the presence of multiple enchondromas involving several bones.
The lesions may occur within the medullary cavity or occasionally closer to the cortical surface.
Ollier Disease
Ollier disease is a form of multiple enchondromatosis that characteristically has an asymmetric distribution.
Although multiple bones can be involved, one side of the body is often affected more extensively than the other.
Familial clustering has rarely been described, but a straightforward inherited pattern is not typical.
Maffucci Syndrome
Maffucci syndrome consists of multiple enchondromas associated with soft-tissue vascular lesions, particularly hemangiomas.
The hands and feet are commonly affected.
Diagnosis
General Clinical Features
Most solitary enchondromas are asymptomatic.
They are frequently discovered incidentally when radiographs are obtained for an unrelated problem.
Pain
Enchondromas of the long bones should not ordinarily produce pain.
When a patient with an intramedullary cartilage lesion has pain, another explanation should be sought, including arthritis, tendinopathy, bursitis, fracture, or a more aggressive cartilaginous tumor such as chondrosarcoma.
Pathologic Fracture
In the hand, enchondromas may weaken the involved phalanx sufficiently to cause a pathologic fracture.
Pain in these patients is usually attributable to the fracture rather than to the tumor itself.
Digital Enlargement
If the lesion occupies a substantial portion of a small tubular bone, mild enlargement or expansion of the affected digit may be visible.
Incidental Discovery
Many lesions are identified on routine radiographs or during imaging performed for another condition.
Enchondromas may also demonstrate increased uptake on bone scintigraphy.
Malignant Transformation
Malignant transformation of a solitary enchondroma is uncommon.
When it occurs, it is more often encountered in long bones than in the small bones of the hand.
Enchondromatosis
Clinical Recognition
Multiple enchondromatosis is often recognized by approximately 10 years of age because of palpable masses, limb shortening, asymmetric growth, or angular deformity.
Distribution
Although lesions may occur on both sides of the body, involvement is frequently much greater on one side.
Within a single extremity, the distribution may also be asymmetric.
Growth Disturbance
When lesions involve the region near the physis, affected bones may become shortened, widened, or deformed.
The severity of deformity depends on the number, size, and location of the lesions.
Course After Puberty
The active growth disturbance generally decreases after skeletal maturity because cartilaginous growth slows substantially.
Maffucci Syndrome
Patients with Maffucci syndrome have multiple enchondromas together with soft-tissue vascular malformations.
Phleboliths may be visible within hemangiomas on radiographs.
The hands and feet are especially commonly affected.
Physical Examination
The involved bone should be examined for tenderness, enlargement, deformity, and an associated soft-tissue mass.
Tenderness should raise concern for fracture, another local pain generator, or a more aggressive process.
Imaging
Plain Radiographs
Plain radiographs in at least two planes are the principal imaging studies.
In children with suspected multifocal disease, additional skeletal imaging may be needed to evaluate for other lesions.
Serial Radiographs
Comparison with previous studies or serial radiographs obtained approximately every 3–6 months can help determine whether the lesion is stable.
A typical enchondroma does not enlarge significantly after skeletal maturity.
Typical Radiographic Appearance
The classic lesion is a well-defined central lytic abnormality within the metaphysis or metadiaphysis.
Mild endosteal scalloping may occur.
Intralesional mineralization is variable.
Cartilage Matrix Mineralization
Typical chondroid mineralization patterns are described as rings and arcs, stippled, punctate, or popcorn-like calcifications.
These reflect enchondral mineralization within the cartilaginous matrix.
Small Tubular Bones
In the phalanges and other small tubular bones, the lesion may occupy most or all of the shaft.
The cortex generally remains intact but may appear mildly expanded or thinned.
Pediatric Appearance
In children, enchondromas may remain almost completely radiolucent because the cartilage has not mineralized.
They may therefore resemble a unicameral bone cyst.
Changes With Age
As patients mature, the initially radiolucent cartilage commonly undergoes increasing enchondral ossification and calcification.
This produces the classic ring-and-stipple appearance seen more often in adults.
Dense Mineralization
Occasionally, mineralization becomes so extensive that the lesion resembles a bone infarct.
Periosteal Reaction
A typical uncomplicated enchondroma does not produce a periosteal reaction.
The development of aggressive periosteal change should raise concern for another diagnosis.
Imaging in Enchondromatosis
Radiographs demonstrate multiple radiolucent cartilaginous lesions, usually centered in the metaphyses.
Calcification may appear irregular and longitudinal or streak-like as the lesions extend from the region of the physis.
Cortical Expansion
Affected bones may expand internally because the enchondromas interfere with normal metaphyseal remodeling.
As a result, the bone may fail to develop its normal tubular contour and can develop clubbed or broadened ends.
Distribution Within Bone
Lesions may be intracortical, subcortical, metaphyseal, or occasionally epiphyseal.
The epiphysis and diaphysis are usually relatively spared, although severe disease may involve nearly the entire bone.
MRI
Signal Characteristics
On MRI, an enchondroma typically appears as a well-circumscribed, lobulated lesion with low signal intensity on T1-weighted images and high signal intensity on T2-weighted images.
Surrounding Tissues
A benign enchondroma should not usually produce significant periosteal reaction or extensive surrounding edema.
Such findings warrant closer assessment for fracture or an aggressive lesion.
Bone Scintigraphy
Enchondromas may demonstrate increased radionuclide uptake and therefore appear “hot” on a bone scan.
This does not by itself imply malignant transformation.
Interpretation of Increased Uptake
Although enchondromas generally do not enlarge, they undergo ongoing remodeling.
Increased tracer uptake can therefore be present in a benign lesion.
A change in uptake compared with previous studies may be more significant than a single positive scan.
Pathological Findings
Microscopic Appearance
Typical enchondromas contain small nests or lobules of cartilage separated by normal marrow.
The chondrocytes are generally bland, without significant atypia.
Calcification
Foci of calcification and enchondral ossification are commonly present.
A thin rim or layer of lamellar bone may also be seen.
Cellular Features
At low magnification, the lesions are usually hypocellular with a blue-gray chondroid matrix and inconspicuous nuclei.
At higher magnification, nuclei are small, uniform, and darkly staining.
Binucleated cells are uncommon in typical long-bone lesions.
Bone Permeation
True permeation of pre-existing trabecular bone is not characteristic of enchondroma.
Infiltrative permeation of marrow and trabeculae raises concern for chondrosarcoma.
Ki-67
Enchondromas generally demonstrate very low proliferative activity, and Ki-67 staining is typically negative or minimal.
Hand Lesions
Enchondromas of the hand may look somewhat more cellular and atypical microscopically than comparable lesions in long bones while still behaving benignly.
They may demonstrate mild myxoid change, increased cellularity, and occasional binucleated cells.
These findings should therefore be interpreted in the context of the lesion’s location and imaging appearance.
Differential Diagnosis
Bone Infarct
A heavily mineralized enchondroma may resemble a bone infarct.
The distribution and pattern of mineralization can help differentiate the two.
Chondrosarcoma
The most important differential diagnosis is low-grade chondrosarcoma, particularly in an adult with a painful or enlarging long-bone lesion.
Enchondroma Versus Low-Grade Chondrosarcoma
Distinguishing a benign enchondroma from an active cartilaginous lesion or low-grade chondrosarcoma can be difficult.
Histologic overlap is substantial, so biopsy alone may not provide a definitive answer.
Diagnosis requires careful correlation of clinical symptoms, serial imaging, lesion location, cortical behavior, and pathology.
Features Favoring Enchondroma
Features supporting enchondroma include absence of pain attributable to the lesion, radiographic stability, relatively uniform matrix mineralization, minimal endosteal erosion, low cellularity, and bland uniform chondrocytes.
Features Suggesting Chondrosarcoma
Concerning findings include persistent lesion-related pain, progressive enlargement, lucent nonmineralized regions, marked endosteal scalloping, cortical thickening or destruction, loss of previously present mineralization, periosteal reaction, increased cellularity, atypia, and permeation of trabecular bone.
Endosteal Scalloping
Deep endosteal erosion involving more than approximately 50% of cortical thickness is more concerning for an aggressive cartilaginous lesion than for a latent enchondroma.
Treatment
General Principles
Most asymptomatic enchondromas do not require surgery.
The principal goals are to confirm radiographic stability and ensure that pain, if present, is not being incorrectly attributed to the lesion.
Evaluation of Pain
Because a typical enchondroma should not cause pain in a long bone, common regional causes should be considered.
For example, pain around a proximal humeral enchondroma may actually arise from rotator cuff disease or glenohumeral arthritis.
Pain near a proximal femoral lesion may result from trochanteric bursitis, hip arthritis, or abductor pathology, while pain near a distal femoral lesion may arise from patellofemoral disease, knee arthritis, or iliotibial-band symptoms.
Activity
Routine activity restriction is generally unnecessary for an uncomplicated enchondroma of a long bone.
Management should instead be based on fracture risk and symptoms.
Hand and Foot Enchondromas
Lesions in the small bones of the hands and feet may weaken the cortex and predispose to fracture.
For this reason, symptomatic or structurally significant lesions are more often treated surgically.
Pathologic Fracture
When a pathologic fracture occurs through a hand enchondroma, the fracture is often allowed to heal first.
Curettage and grafting can then be performed after union if the lesion remains clinically significant.
Surgery
Long-Bone Lesions
Surgery is usually unnecessary for a stable, asymptomatic enchondroma of a long bone.
Observation with serial imaging is generally sufficient.
Curettage
Symptomatic hand lesions are commonly treated by intralesional curettage.
The cartilaginous tissue is removed through a cortical window.
Bone Grafting
Following curettage, the defect may be filled with bone graft or another suitable bone substitute, particularly when substantial structural weakness remains.
Surgical Approach in the Phalanx
A small cortical window can be created along the lateral aspect of the involved phalanx.
The lesion is then thoroughly curetted, and the residual cavity may be grafted.
Enchondromatosis Treatment
Angular Deformity
Surgery may be required when multiple enchondromas cause significant angular deformity.
Corrective osteotomy can be performed, including through involved bone when appropriate.
Limb-Length Discrepancy
Clinically significant limb-length inequality may be managed with epiphysiodesis or limb-lengthening procedures, depending on patient age and the magnitude of discrepancy.
Hand Disease
Large hand lesions that interfere with function or substantially weaken the bone may require curettage and grafting.
Follow-Up
Patients with solitary long-bone enchondromas are commonly followed with serial radiographs at approximately 3–6-month intervals initially, often for 1–2 years.
If the lesion remains stable, surveillance can usually become less frequent.
Return Precautions
Patients should return for reassessment if the involved extremity develops new persistent pain, swelling, or other changes, because these may indicate fracture or more aggressive biological behavior.
Referral
Patients with a cartilage lesion and unexplained musculoskeletal pain should be considered for referral to an orthopaedic oncologist, particularly when radiographic findings are atypical or there is concern for chondrosarcoma.
Complications
Malignant Transformation
The principal oncologic complication is transformation to chondrosarcoma, although this is uncommon in solitary enchondromas.
New pain and documented lesion growth are particularly concerning.
Ollier Disease
Patients with enchondromatosis have a substantially greater risk of malignant transformation than patients with solitary enchondroma.
Historical series have reported development of chondrosarcoma in approximately 30% of patients with Ollier disease, commonly during the third or fourth decades of life.
Maffucci Syndrome
The risk of malignancy is particularly high in Maffucci syndrome.
Affected patients are predisposed not only to chondrosarcoma but also to other malignancies involving organs such as the brain and pancreas.
Patient Monitoring
Monitoring should focus on clinical symptoms and serial radiographic behavior.
Important warning features include new lesion-related pain, enlargement, increasing cortical erosion, cortical destruction, new periosteal reaction, loss of mineralization, or development of a soft-tissue mass.
Patients with Ollier disease or Maffucci syndrome require more prolonged surveillance because of their substantially higher risk of malignant transformation.
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Orthopaedic Surgery - Elbow Dislocation
Basics
Elbow dislocation is usually the result of acute trauma, most often involving disruption of the ulnohumeral articulation.
Posterior dislocation is by far the most common pattern.
The injury occurs most frequently in younger patients, particularly those under 20 years of age, although it may also occur in older adults after a fall.
Approximately 26% of elbow dislocations are associated with a fracture.
Classification
Elbow dislocations are generally named according to the position of the ulna relative to the humerus after injury.
They may be classified as posterior, anterior, medial, lateral, or divergent.
Posterior and posterolateral patterns are the most frequently encountered.
Fracture-Dislocation
An elbow dislocation associated with fractures of the radial head and coronoid process is referred to as the terrible triad of the elbow.
This is a complex unstable injury with a substantially worse prognosis than an uncomplicated simple dislocation.
Coronoid Fracture Classification
Coronoid fractures have traditionally been divided into three types.
Type I is an avulsion fracture involving the tip of the coronoid.
Type II involves up to approximately 50% of the coronoid.
Type III involves more than 50% of the coronoid.
Larger coronoid fractures are more often associated with major anterior or posterior fracture-dislocations, while smaller transverse fragments are frequently seen in terrible-triad injuries.
Epidemiology
The highest incidence of elbow dislocation occurs in patients younger than 20 years of age.
Among children, elbow fractures and dislocations together account for approximately 3–6% of pediatric skeletal injuries.
Risk Factors
Participation in sports increases the risk of elbow dislocation.
Snowboarding has been associated with a greater risk of elbow dislocation than skiing, largely because falls onto an outstretched upper extremity are common.
Pathophysiology
Posterior elbow dislocation most often results from a fall onto an outstretched hand.
Axial loading and valgus or rotational forces transmitted through the forearm disrupt the stabilizing structures of the elbow.
Soft-Tissue Injury
The collateral ligaments are usually injured during a posterior dislocation.
The brachialis muscle and coronoid region may also be damaged.
The severity of ligament disruption determines post-reduction stability.
Associated Injuries
Elbow dislocation may occur with fractures of the radius, ulna, or distal humerus.
Neurologic and vascular injuries can also occur.
Nerve Injury
The ulnar and median nerves are particularly vulnerable.
The median nerve can become entrapped within the joint, including during reduction, so its function must be documented carefully before and after the procedure.
Brachial Artery Injury
The brachial artery may be stretched, compressed, disrupted, or trapped within the dislocated joint.
Vascular compromise is a limb-threatening problem and requires urgent surgical assessment.
Diagnosis
Signs and Symptoms
The typical patient presents after trauma with severe elbow pain, swelling, obvious deformity, and inability or unwillingness to move the elbow.
The normal contour of the elbow may be markedly distorted.
Physical Examination
Neurovascular Examination
A complete neurovascular assessment is essential before any attempt at reduction.
Motor and sensory function of the radial, median, and ulnar nerves should be documented.
Median Nerve
Median nerve function deserves particular attention because the nerve may become entrapped during the injury or during reduction.
A clearly documented pre-reduction examination is important for distinguishing traumatic injury from an iatrogenic change.
Ulnar and Radial Nerves
Ulnar and radial nerve motor and sensory function should also be evaluated carefully.
Any abnormality should be documented and reassessed after reduction.
Vascular Examination
The brachial artery and distal perfusion should be assessed before reduction.
The examination should include radial and ulnar pulses, capillary refill, skin temperature, and overall hand perfusion.
Vascular Injury
Loss of perfusion or evidence of arterial entrapment requires immediate orthopaedic and vascular surgical evaluation.
Examination for Associated Injury
The entire upper extremity should be inspected because associated injuries are common.
The clinician should specifically evaluate the shoulder, forearm, wrist, and distal radioulnar joint.
Monteggia Injury
A Monteggia fracture-dislocation should be excluded when forearm pain or deformity accompanies an apparent elbow injury.
Compartment Syndrome
The forearm should be palpated for increasing firmness, swelling, or pain suggestive of compartment syndrome.
Serial examination is particularly important in high-energy injuries.
Imaging
Plain Radiographs
AP and lateral radiographs of the elbow are generally sufficient to confirm the direction of the dislocation.
Whenever practical, imaging should be obtained without an obscuring splint so that associated fractures and subtle joint incongruity are not missed.
Post-Reduction Radiographs
Radiographs should also be obtained after reduction to confirm concentric joint alignment and identify associated fractures that may have been difficult to appreciate initially.
CT
CT is especially useful in fracture-dislocations.
It defines the size, location, and displacement of coronoid, radial head, and other articular fragments and assists with surgical planning.
MRI
MRI can demonstrate collateral ligament and other soft-tissue injuries.
It is not routinely required for uncomplicated acute dislocations but may be useful when persistent instability or associated soft-tissue pathology is suspected.
Differential Diagnosis
The main diagnostic concern is an associated fracture or fracture-dislocation rather than a separate condition.
Careful imaging is therefore required to identify coronoid, radial head, olecranon, distal humeral, or forearm fractures.
Initial Treatment
Emergency Measures
The injured arm should be immobilized, elevated, and treated with ice while urgent evaluation is arranged.
An acute elbow dislocation requires prompt emergency assessment.
Neurovascular Documentation
Neurovascular status must be recorded before and after reduction.
Any deterioration following reduction requires urgent reassessment.
Radiographic Evaluation
Radiographs are obtained to define the dislocation and identify associated fractures whenever the clinical condition permits.
Closed Reduction
Most simple elbow dislocations can be treated with closed reduction under appropriate analgesia, sedation, or anesthesia.
Posterior Dislocation Reduction
Posterior or posterolateral dislocations are commonly reduced using gentle longitudinal traction combined with gradual elbow flexion and directed pressure on the forearm or olecranon.
Forceful manipulation should be avoided.
Confirmation of Reduction
Successful reduction is suggested by restoration of elbow contour and improved motion.
Radiographic confirmation is required.
Post-Reduction Examination
Range of Motion
Following reduction, the elbow should be taken gently through flexion and extension to assess stability and determine the safe arc of motion.
Ligamentous Stability
Gentle valgus and varus stress testing may be performed to assess collateral ligament competence.
Gross instability after reduction raises concern for major ligament disruption or associated fracture.
Repeat Neurovascular Examination
Radial, median, and ulnar nerve function and distal vascular status must be rechecked immediately after reduction.
Immobilization
A posterior splint with the elbow at approximately 90° of flexion is commonly used initially.
The exact position may be modified according to stability and associated injury.
Duration
Immobilization is generally brief, often approximately 1 week in a stable simple dislocation.
Prolonged immobilization should be avoided because the elbow is highly prone to stiffness.
Immobilization beyond about 3 weeks substantially increases the risk of persistent motion loss.
Activity
After immobilization is discontinued, gradual active and passive motion should begin.
Heavy lifting should initially be avoided, with progression determined by pain, stability, and recovery.
Physical Therapy
Rehabilitation emphasizes restoration of range of motion followed by progressive strengthening.
Early controlled motion is one of the most important measures for minimizing post-dislocation elbow stiffness.
Surgery
Indications
Surgical treatment is indicated for irreducible dislocation, open dislocation, neurovascular entrapment, selected associated fractures, and unstable complex fracture-dislocations.
Irreducible Dislocation
Failure of closed reduction may result from soft-tissue interposition, an entrapped nerve, or an intra-articular fracture fragment.
Open reduction is then required.
Open Dislocation
Open elbow dislocations require urgent operative irrigation, debridement, reduction, and stabilization as appropriate.
Neurovascular Entrapment
Entrapment of the brachial artery, median nerve, or other critical structures is an indication for operative exploration.
Fracture Fixation
Open reduction and internal fixation may be required for associated displaced radial head fractures, olecranon fractures, distal humeral fractures, or other unstable osseous injuries.
Complex Fracture-Dislocations
The central objective in treating a complex fracture-dislocation is to restore the articular surface and recreate stable elbow mechanics.
Coronoid Repair
The coronoid should be repaired when necessary because it is an important anterior stabilizer of the elbow.
Radial Head Reconstruction
The radial head should be preserved and reconstructed when possible.
When the fracture is not reconstructable, radial head replacement may be required to restore stability.
Collateral Ligament Repair
Repair of the lateral and, when necessary, medial collateral ligament complexes may be needed to obtain a stable joint.
Terrible Triad Reconstruction
Management of the terrible triad commonly involves coronoid fixation, restoration or replacement of the radial head, and repair of the lateral collateral ligament complex, with additional procedures based on residual instability.
Total Elbow Arthroplasty
Total elbow arthroplasty may occasionally be considered for selected elderly patients with severe unreconstructable fracture-dislocations or neglected injuries.
It is generally reserved for low-demand patients because of postoperative lifting restrictions and implant-related complications.
Follow-Up
Prognosis
Most patients with a simple elbow dislocation treated with prompt closed reduction and early motion achieve a good functional outcome.
Residual Loss of Motion
The most frequent residual problem is loss of terminal extension.
A persistent deficit of approximately 10–15° of extension is common and often causes little functional impairment.
Instability
Persistent medial or valgus instability can predispose to chronic pain and secondary degenerative arthritis.
Role of Surgery in Simple Dislocation
Routine surgical repair has not generally been shown to improve outcomes in uncomplicated elbow dislocations without associated fracture or persistent instability.
Most such injuries are therefore managed nonoperatively.
Complex Injuries
Complex fracture-dislocations have a less favorable prognosis.
Aggressive reconstruction aimed at restoring stable anatomy and permitting early motion generally provides the best chance of functional recovery.
Complications
Loss of Motion
Elbow stiffness is the most common complication.
Loss of extension is more common than severe flexion loss.
Neurovascular Injury
Persistent nerve dysfunction or vascular injury may occur from the initial trauma, entrapment, swelling, or less commonly as a complication of reduction.
Chronic Pain
Some patients develop persistent pain because of residual instability, cartilage injury, heterotopic ossification, or post-traumatic arthritis.
Post-Traumatic Arthritis
Articular injury and chronic instability can lead to degenerative changes over time.
Recurrent or Persistent Instability
Failure of the collateral ligaments or inadequate healing may result in chronic valgus, varus, or posterolateral rotatory instability.
Heterotopic Ossification
Heterotopic bone formation can develop in the periarticular soft tissues after severe trauma.
It may contribute to pain and restriction of elbow motion.
Patient Monitoring
Follow-up frequency depends on injury severity and stability.
In a stable simple dislocation, immobilization is usually maintained for approximately 1 week, followed by early motion.
Immobilization should generally remain shorter than 3 weeks whenever stability permits.
During the first 12–24 hours, close monitoring should include neurovascular function, forearm compartment status, pain, swelling, and hand perfusion.
Subsequent follow-up should assess range of motion, stability, neurologic recovery, associated fracture healing, and development of heterotopic ossification or post-traumatic arthritis.
