Orthopaedic Surgery - Cervical Spine Anatomy and Examination

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Basics

The cervical spine consists of seven cervical vertebrae, C1 through C7, which support the head, protect the spinal cord, permit a wide range of motion, and provide passage for important neurovascular structures.

For practical purposes, the cervical spine can be divided into the upper cervical spine, consisting of C1 and C2, and the lower cervical spine, consisting of C3 through C7.

The upper and lower regions differ substantially in both morphology and function.

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Osteology

Typical cervical vertebrae contain a vertebral body, paired pedicles, paired laminae, transverse processes, articular structures, and a spinous process.

The bony architecture surrounds and protects the cervical spinal cord while contributing to stability and motion.

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Transverse Foramina

All cervical vertebrae contain transverse foramina within their transverse processes.

The vertebral arteries usually pass through the transverse foramina from C6 to C1, rather than through C7.

Protection of these vessels is one of the important functions of intact cervical vertebral anatomy.

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Upper Cervical Spine

The atlas (C1) and axis (C2) are considered atypical cervical vertebrae because their anatomy differs considerably from that of C3–C7.

Their specialized architecture allows extensive movement between the skull and upper cervical spine.

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Atlas

The atlas has no true vertebral body and no conventional spinous process.

It consists largely of anterior and posterior arches connected by lateral masses.

C1 articulates superiorly with the occipital condyles and inferiorly with the axis.

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Atlantoaxial Joint

The articulation between C1 and C2 forms the atlantoaxial joint.

Approximately 50% of cervical rotation occurs at this level.

The unique articulation between the atlas and odontoid process permits substantial axial rotation of the head.

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Axis

The axis (C2) contains a vertebral body and the characteristic odontoid process, or dens, which projects superiorly and acts as a pivot for rotation of C1.

The dens is clinically important because odontoid fractures are common upper cervical injuries.

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Odontoid Blood Supply

The odontoid process contains a relative vascular watershed region between its apex and base.

This limited blood supply can influence healing of certain odontoid fractures and contributes to the risk of nonunion in selected fracture patterns.

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Atlanto-Occipital Joint

A substantial proportion of upper cervical flexion and extension occurs at the atlanto-occipital articulation between the occiput and C1.

This joint is particularly important for nodding movements of the head.

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Cervical Lordosis

The normal sagittal alignment of the cervical spine is lordotic.

Loss or reversal of cervical lordosis may be associated with muscle spasm, degeneration, deformity, or traumatic injury, although alignment must always be interpreted in clinical context.

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Protective Function

Normal cervical vertebral anatomy protects both the spinal cord and vertebral arteries.

Trauma, instability, stenosis, or deformity can therefore have serious neurologic or vascular consequences.

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Neuroanatomy

There are eight cervical nerve roots despite only seven cervical vertebrae.

The cervical nerve roots generally exit above their correspondingly numbered vertebrae.

For example, the C5 nerve root exits between C4 and C5.

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C8 Nerve Root

The C8 nerve root exits between C7 and T1.

Below this level, thoracic and lumbar nerve roots exit below the correspondingly numbered vertebra.

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Orientation of Cervical Nerve Roots

Cervical nerve roots travel in a relatively horizontal direction as they leave the spinal canal.

Because of this arrangement, both central/paracentral and foraminal disc pathology may affect the same exiting cervical nerve root depending on the level and location of compression.

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Cervical Spine Examination

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Inspection

The examination should begin with visual inspection.

Adequate exposure is important so that the neck, shoulders, upper thorax, and surrounding soft tissues can be assessed systematically.

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Alignment

The examiner should assess gross cervical alignment and head position.

Abnormal posture, torticollis, deformity, or asymmetry may indicate muscle spasm, structural deformity, or neurologic disease.

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Skin and Soft Tissues

The skin should be inspected for wounds, scars, bruising, swelling, masses, or other soft-tissue abnormalities.

Muscle asymmetry, atrophy, or hypertrophy should also be noted.

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Anterior Bony Palpation

Palpation of the anterior neck should identify tenderness, crepitus, masses, asymmetry, or malalignment.

Several palpable landmarks can help estimate cervical spinal levels.

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Hyoid Bone

The hyoid bone approximately corresponds to the level of the C3 vertebral body.

It can serve as a useful surface landmark during examination.

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Thyroid Cartilage

The superior portion of the thyroid cartilage approximately corresponds to the C4 vertebral body.

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Cricoid Cartilage

The cricoid cartilage is located approximately at the C6 vertebral level.

It may be easier to palpate during swallowing because movement of the laryngeal structures makes the anatomy more distinct.

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Carotid Tubercle

The anterior tubercle of the C6 transverse process is known as the carotid tubercle.

The right and left carotid tubercles should not be compressed simultaneously because doing so could reduce blood flow through both carotid arteries.

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Tracheal Examination

The trachea should be palpated to confirm that it remains in the midline.

Deviation may indicate a mass, swelling, mediastinal process, or other abnormality.

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Posterior Bony Palpation

Posterior examination begins at the occiput and proceeds inferiorly along the cervical spinous processes.

Tenderness, step-off, displacement, or asymmetry should be noted.

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Inion

The inion is the most prominent palpable point of the lower occiput.

It serves as an important posterior surface landmark.

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Spinous Processes

The spinous processes should generally form a straight midline sequence.

C7 and T1 are usually the most prominent and easiest to palpate.

Deviation from normal alignment can suggest rotational injury, including unilateral facet dislocation.

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Bifid Spinous Processes

The spinous processes of approximately C3–C5 may be bifid.

This is a normal anatomical variation and should not be mistaken for pathology.

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Facet Joints

The cervical facet joints lie approximately 2.5 cm lateral to the spinous processes.

Degenerative disease frequently affects the lower cervical facets, particularly around C5–C6.

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Anterior Soft-Tissue Palpation

Anterior soft-tissue examination should include the sternocleidomastoid muscles, parotid glands, cervical lymph nodes, thyroid gland, carotid pulses, and supraclavicular fossae.

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Thyroid Examination

The thyroid gland should normally feel relatively smooth and symmetric.

Enlargement, nodularity, or asymmetry should be documented.

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Supraclavicular Fossa

The supraclavicular area should be palpated for abnormal masses or bony prominences.

A prominent structure may represent a cervical rib.

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Posterior Soft-Tissue Palpation

Posterior soft-tissue examination includes the trapezius muscles, greater occipital nerves, and ligamentum nuchae.

The trapezius should be assessed for tenderness, muscle asymmetry, or abnormal masses.

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Lymph Nodes

Palpable lymph nodes in the posterior neck should be considered abnormal if enlarged or otherwise clinically suspicious.

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Greater Occipital Nerves

The greater occipital nerves can become tender or prominent after trauma, including whiplash-type injuries.

Irritation may contribute to occipital pain or headache.

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Ligamentum Nuchae

The ligamentum nuchae extends from the inion to the C7 spinous process.

It can be palpated in the posterior midline.

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Neurologic Examination

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General Principles

Neurologic evaluation of the cervical spine includes sensory, motor, and reflex testing.

Findings should be carefully documented to identify nerve-root compression, spinal cord dysfunction, or peripheral neuropathy.

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Sensory Examination

Patients should be asked to identify altered sensation as specifically as possible.

The most commonly assessed sensory modalities are light touch and pinprick.

Comparison between sides is useful.

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Upper Cervical Dermatomes

Sensation from C2 through C4 generally progresses from the posterior scalp and neck toward the anterior neck and shoulder region.

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C5 Dermatome

The C5 dermatome is represented mainly over the lateral shoulder and upper arm.

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C6 Dermatome

The C6 dermatome extends along the lateral forearm toward the radial side of the hand, particularly the thumb and adjacent radial digits.

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C7 Dermatome

The C7 dermatome is commonly tested at the middle finger.

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C8 Dermatome

The C8 dermatome involves the ulnar side of the hand, particularly the ring and little fingers.

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T1 Dermatome

The T1 dermatome lies primarily along the medial forearm.

Dermatomal patterns overlap, so sensory findings should always be interpreted together with motor and reflex abnormalities.

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Motor Examination

Motor testing should evaluate major muscle groups corresponding to cervical nerve roots.

Strength should be graded consistently to allow changes over time to be recognized.

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Muscle Strength Grading

Grade 0: No visible or palpable muscle contraction.

Grade I: Muscle contraction is visible or palpable, but no joint movement occurs.

Grade II: Full range of motion is possible with gravity eliminated.

Grade III: Full range of motion is possible against gravity.

Grade IV: Full range of motion is possible against gravity and some resistance.

Grade V: Normal strength against full resistance.

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C3–C5 Motor Function

The levator scapulae can be assessed with resisted scapular elevation and receives contributions predominantly from C3 and C4, with possible C5 involvement.

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C5 Motor Function

The deltoid is tested with shoulder abduction and primarily reflects C5 motor function.

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C6 Motor Function

C6 function can be evaluated with elbow flexion through the biceps and wrist extension.

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C7 Motor Function

C7 is assessed through triceps-mediated elbow extension, wrist flexion, and finger extension.

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C8 Motor Function

C8 contributes substantially to finger flexion and thumb adduction.

Testing grip and intrinsic hand function can therefore help assess lower cervical nerve-root function.

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Deep Tendon Reflexes

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Reflex Examination

Deep tendon reflex testing helps distinguish nerve-root compression from spinal cord disease.

Diminished reflexes may indicate radiculopathy, whereas hyperreflexia can suggest an upper motor neuron lesion such as cervical myelopathy.

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Biceps Reflex

The biceps reflex primarily evaluates the C5 nerve root, with some contribution from C6.

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Brachioradialis Reflex

The brachioradialis reflex primarily evaluates C6.

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Triceps Reflex

The triceps reflex primarily evaluates C7.

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Range of Motion

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General Principles

Active cervical range of motion should be assessed in flexion, extension, rotation, and lateral bending.

Pain, limitation, asymmetry, and reproduction of radicular symptoms should be noted.

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Flexion and Extension

A large proportion of flexion-extension occurs in the upper cervical spine, while the remainder is distributed across the subaxial cervical levels.

The C5–C6 segment often demonstrates particularly substantial motion.

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Muscles Used in Flexion and Extension

Cervical flexion assesses muscles including the sternocleidomastoid and deeper cervical flexors.

Extension involves the paraspinal extensors and trapezius.

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Rotation

Approximately half of cervical rotation occurs at C1–C2, with the remainder distributed through the lower cervical spine.

The patient should normally be able to rotate the chin approximately 60–80° to either side.

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Rotational Muscles

The sternocleidomastoid is an important cervical rotator, although normal rotation is produced by coordinated activity of several muscle groups.

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Lateral Bending

Lateral bending is distributed throughout the cervical spine and usually occurs in combination with some rotation.

The patient is asked to bring the ear toward the ipsilateral shoulder without elevating the shoulder.

Normal lateral bending is approximately 45°.

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Muscles Used in Lateral Bending

The scalene muscles contribute substantially to cervical lateral flexion.

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Provocative Tests

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Modified Spurling Maneuver

The modified Spurling test evaluates cervical nerve-root irritation.

The neck is extended and rotated toward the symptomatic side, followed by gentle axial loading.

A positive test reproduces radicular pain or paresthesias in the ipsilateral upper extremity.

The test is relatively specific for cervical radiculopathy but has limited sensitivity.

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Shoulder Abduction Test

The patient actively or passively raises the symptomatic arm over the head.

Relief of radicular symptoms with ipsilateral shoulder abduction constitutes a positive test and may suggest cervical nerve-root compression.

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Cervical Distraction Test

The examiner applies gentle longitudinal traction to the head, typically with the neck in slight flexion or neutral alignment.

Improvement in radicular symptoms during distraction supports the possibility of cervical nerve-root compression.

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Lhermitte Sign

The Lhermitte maneuver is performed by flexing the cervical spine anteriorly.

An electric or shooting sensation traveling down the arms, trunk, or legs suggests irritation or dysfunction of the cervical spinal cord.

It may occur with cervical cord compression as well as other disorders affecting the dorsal columns.

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Hoffmann Sign

To test the Hoffmann reflex, the patient’s hand is supported and relaxed.

The examiner grasps the middle finger and sharply flicks the distal phalanx or nail.

A positive response consists of reflex flexion or adduction of the thumb and index finger.

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Significance of Hoffmann Sign

A positive Hoffmann sign can suggest upper motor neuron or corticospinal tract dysfunction, including cervical myelopathy.

It should not be interpreted in isolation and must be correlated with the remainder of the neurologic examination.

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Romberg Test

The Romberg test evaluates balance and proprioception.

The patient stands with the arms extended and eyes initially open, then closed.

Loss of balance when the eyes are closed suggests impaired proprioceptive function.

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Dynamic Balance Assessment

Observation of abnormal arm drift, progressive elevation of the arms, or instability during static or dynamic balance testing may provide additional evidence of neurologic dysfunction.

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Gait Assessment

Gait examination is an essential part of cervical neurologic evaluation.

It can provide information regarding balance, coordination, lower-extremity function, posture, spasticity, and possible spinal cord dysfunction.

Patients with cervical myelopathy may exhibit a stiff, broad-based, unsteady, or spastic gait.

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Imaging

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Plain Radiographs

Standard cervical spine radiography commonly includes anteroposterior and lateral views.

When possible, imaging is obtained with the patient upright so that physiologic alignment can be assessed.

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Trauma Radiographs

In trauma patients, an initial cross-table lateral radiograph may be used when appropriate, but the entire cervical spine must be adequately visualized for the image to be diagnostically useful.

Modern trauma evaluation frequently relies heavily on CT when significant cervical injury is suspected.

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Oblique Views

Oblique radiographs can help assess the neural foramina, facet alignment, subluxation, and facet dislocation.

They are particularly helpful in selected cases when foraminal anatomy requires further evaluation.

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Open-Mouth Odontoid View

The open-mouth view is used to assess the odontoid process, atlantoaxial joints, and alignment of the lateral masses of C1 relative to C2.

Asymmetry may indicate fracture, displacement, or rotational injury.

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Pediatric Radiographs

In young children, normal ossification centers and developmental variants may resemble fractures.

Knowledge of age-related cervical spine anatomy is therefore essential to avoid misinterpreting normal findings as traumatic injury.

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MRI

MRI is the preferred modality for evaluating soft-tissue structures of the cervical spine.

It provides detailed visualization of the intervertebral discs, spinal cord, nerve roots, ligaments, joint capsules, and other neural and soft-tissue structures.

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Clinical Role of MRI

MRI findings should be correlated with the patient’s symptoms and physical examination because asymptomatic degenerative abnormalities are common.

It is particularly valuable when evaluating disc herniation, spinal stenosis, ligamentous injury, spinal cord compression, and myelopathy.

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CT

CT provides excellent definition of cervical osseous anatomy.

It can rapidly and accurately identify fractures, facet injuries, displacement, and complex bony abnormalities.

For suspected cervical spine trauma, CT is particularly useful for fracture characterization and surgical planning.

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Integration of Examination and Imaging

Cervical spine assessment requires correlation of history, physical examination, neurologic findings, provocative testing, and imaging.

No single examination maneuver or imaging abnormality should be interpreted in isolation.

A systematic approach is particularly important when distinguishing cervical radiculopathy, myelopathy, structural injury, and peripheral nerve disease.

Orthopaedic Surgery - Cervical Disc Herniation

Basics

Cervical disc herniation occurs when intervertebral disc material displaces posteriorly into the spinal canal or neural foramen, resulting in compression of a cervical nerve root, the spinal cord, or both.

Mechanical compression is accompanied by an inflammatory response and may produce neck pain, cervical radiculopathy, cervical myelopathy, or a combination of these findings.

Classification

Cervical disc herniations may be classified according to clinical onset, anatomic location, or the morphology of the displaced disc material.

Clinically, the condition may present acutely or develop gradually.

Anatomically, the herniation may be central, paracentral, foraminal, or lateral depending on its location within the spinal canal.

Classification by Disc Morphology

Disc displacement can also be described as a bulge, protrusion, extrusion, or sequestration.

A protrusion remains broadly connected with the parent disc, whereas an extrusion represents greater displacement of disc material through the annulus.

A sequestrated fragment has completely separated from the parent disc.

Classification of Myelopathy

Several classification systems are available for cervical myelopathy.

These systems generally assess factors such as gait, pain, upper- and lower-extremity weakness, upper and lower motor neuron findings, bladder function, and fine motor ability.

The purpose is to quantify severity and monitor neurologic progression or response to treatment.

Epidemiology

Cervical disc herniation occurs most commonly in adults older than 30 years, with an average age near 50 years.

Cervical radiculopathy is considerably more common than cervical myelopathy, and radiculopathy only rarely progresses to spinal cord dysfunction.

Incidence

The reported annual age-adjusted incidence of cervical radiculopathy is approximately 107.3 per 100,000 men and 64.5 per 100,000 women.

The incidence is particularly high in adults aged 50–54 years, reaching approximately 203 per 100,000 people per year.

Prevalence of Neck Pain

Neck pain is extremely common.

As many as two-thirds of adults experience at least one significant episode of neck pain during their lifetime.

Not all neck pain, however, is caused by cervical disc herniation.

Risk Factors

Risk factors include repetitive lifting, cigarette smoking, and prolonged or repetitive overhead work.

These activities may increase mechanical stress on the cervical spine or accelerate degenerative disc changes.

Pathophysiology

The mechanical component of cervical nerve compression is well established.

However, symptoms are not produced by compression alone.

Mechanical, ischemic, and inflammatory mechanisms all contribute to nerve-root and spinal-cord dysfunction.

Inflammatory Mediators

Chemical mediators released around the compressed nerve root can contribute to pain and irritation.

These include substance P, interleukin-1, interleukin-6, bradykinin, tumor necrosis factor-alpha, and prostaglandins.

This inflammatory response helps explain why symptoms may be severe even when radiographic compression appears relatively modest.

Etiology

Cervical disc herniations may occur following trauma or may develop without a specific traumatic event as part of degenerative disc disease.

Age-related degeneration weakens the annulus fibrosus and allows nucleus pulposus material to migrate posteriorly.

Associated Conditions

Cervical disc herniation may coexist with congenital cervical spinal stenosis, ossification of the posterior longitudinal ligament, and cervical spondylosis.

These abnormalities reduce the available space for the spinal cord and nerve roots and may increase the clinical significance of even relatively small disc protrusions.

Diagnosis

Signs and Symptoms

Symptoms may begin suddenly or develop gradually.

The clinical spectrum includes neck pain, occipital pain, shoulder-girdle discomfort, arm pain, paresthesias, sensory loss, and weakness.

Symptoms are often aggravated by particular positions or movements of the neck.

Cervical Radiculopathy

Compression of an individual cervical nerve root may produce a characteristic combination of motor weakness, sensory disturbance, pain, and reflex changes.

Although classic dermatomal and myotomal patterns are useful, actual symptoms may overlap and do not always follow a perfectly defined distribution.

Spurling Test

The Spurling maneuver can reproduce radicular symptoms.

The patient’s neck is extended, rotated, and laterally bent toward the symptomatic side, followed by gentle axial compression.

Reproduction of radiating pain or paresthesias into the ipsilateral arm supports cervical nerve-root irritation.

Cervical Myelopathy

Cervical myelopathy usually develops insidiously and may follow a gradual, stepwise pattern of neurologic decline.

Only a small proportion of patients experience rapid deterioration.

Because spinal cord dysfunction can become irreversible, early recognition is important.

Symptoms of Myelopathy

Typical symptoms include progressive gait disturbance, imbalance, falls, deterioration in hand dexterity, generalized weakness, and difficulty with fine motor tasks.

Patients may describe their legs as stiff or “jumpy” and may notice increasing difficulty with buttons, handwriting, or handling small objects.

Advanced Myelopathic Symptoms

More advanced spinal cord dysfunction can produce bowel, bladder, or sexual dysfunction.

These symptoms warrant prompt neurologic and surgical evaluation.

History

Patients should be questioned about the onset, duration, distribution, and progression of pain, paresthesias, numbness, and weakness.

The clinician should also specifically ask about balance problems, falls, gait changes, loss of hand dexterity, and bowel or bladder symptoms.

Sensory Symptoms

Sensory abnormalities do not always follow a precise dermatome.

Overlap between adjacent cervical nerve roots is common, and symptoms may be modified by coexisting peripheral nerve compression.

Physical Examination

The cervical spine should be assessed for range of motion, tenderness, and reproduction of symptoms with movement.

A complete neurologic examination of the upper and lower extremities should include motor testing, sensory testing, reflexes, gait assessment, and examination for long-tract signs.

Motor Examination

Muscle strength should be tested systematically to identify weakness corresponding to a particular cervical nerve root.

Weakness may involve the shoulder, elbow, wrist, or hand depending on the level of compression.

Reflex Examination

Important reflexes include:

C5 – biceps reflex

C6 – brachioradialis reflex

C7 – triceps reflex

Asymmetry or reduction may support a cervical radiculopathy, whereas generalized hyperreflexia can suggest myelopathy.

Babinski Sign

The Babinski response is tested by applying a noxious stimulus along the plantar aspect of the foot.

A positive test consists of extension of the great toe, often accompanied by fanning of the lesser toes.

This suggests an upper motor neuron abnormality and may occur in cervical myelopathy.

Hoffmann Reflex

The Hoffmann reflex is elicited by flicking or pinching the distal phalanx or nail of the middle finger.

A positive response causes reflex flexion or adduction of the thumb and index finger.

When present in the appropriate clinical context, it may indicate cervical spinal cord dysfunction.

Finger Escape Sign

The finger escape sign is associated with cervical myelopathy.

The small finger gradually abducts away from the other digits when the patient attempts to keep the fingers fully extended and adducted.

This reflects weakness or dysfunction of the intrinsic hand muscles.

Electrodiagnostic Testing

Electromyography and nerve conduction studies can provide objective evidence of neurologic dysfunction.

They are particularly useful when there is concern for coexisting peripheral neuropathy, peripheral nerve entrapment, or inconsistency between the history, physical examination, and imaging findings.

Imaging

Plain Radiographs

Conventional cervical spine radiographs can demonstrate alignment, disc-space narrowing, osteophytes, and other degenerative changes.

Oblique views may help visualize the neural foramina.

Flexion-extension radiographs can be used when instability is suspected.

Limitations of Radiographs

Degenerative changes are common in asymptomatic adults, particularly after the age of 40.

Therefore, plain radiographs should be interpreted in conjunction with the clinical picture rather than assumed to identify the source of symptoms.

They are particularly useful after trauma or when symptoms have failed to improve with conservative care.

MRI

MRI is the preferred noninvasive imaging study for most patients who require advanced evaluation.

It provides excellent visualization of intervertebral discs, spinal cord, nerve roots, ligaments, and other soft tissues without ionizing radiation.

Indications for MRI

MRI is particularly useful in patients with persistent radicular symptoms, progressive neurologic deficit, suspected myelopathy, or failure of conservative treatment.

The imaging findings should correlate with the patient’s symptoms and physical examination.

CT Myelography

CT myelography provides detailed assessment of compression from both bone and soft tissue.

It can be useful when MRI cannot be performed or when metallic hardware significantly limits MRI quality.

Because CT myelography is invasive, it is generally reserved for selected situations.

Selective Diagnostic Injections

Selective cervical nerve-root injections may occasionally be used when multiple potential sites of compression are present and the symptomatic level is unclear.

Temporary relief following injection can help identify the primary pain generator.

Pathologic Findings

The fundamental abnormality is herniation of nucleus pulposus material through or beyond the annulus fibrosus.

Compression of a nerve root produces radiculopathy, whereas compression of the spinal cord may cause myelopathy.

Differential Diagnosis

Cervical disc herniation can mimic numerous shoulder, peripheral nerve, neurologic, infectious, or neoplastic disorders.

A careful examination is therefore necessary before attributing upper-extremity symptoms solely to the cervical spine.

Shoulder and Upper-Extremity Disorders

Intrinsic disorders of the shoulder, elbow, or wrist can produce similar symptoms.

These include degenerative arthritis, shoulder impingement, rotator cuff disease, and joint instability.

Peripheral Nerve Entrapment

Peripheral nerve compression should also be considered.

Important examples include carpal tunnel syndrome, cubital tunnel syndrome, Guyon canal syndrome, and thoracic outlet syndrome.

Neurologic Disorders

Neurologic conditions that may mimic cervical radiculopathy or myelopathy include brachial plexopathy, multiple sclerosis, amyotrophic lateral sclerosis, and tumors of the brain or spinal cord.

Infection and Malignancy

Serious alternative diagnoses include infectious discitis, vertebral osteomyelitis, and metastatic malignancy.

Systemic symptoms, severe unremitting pain, fever, weight loss, or a history of cancer should prompt further investigation.

Treatment

General Measures

Most patients with cervical radiculopathy can initially be treated nonoperatively.

Management may include activity modification, analgesic medication, anti-inflammatory therapy, short-term muscle relaxants, selective use of a soft cervical collar, and physical therapy.

Natural History

Cervical radiculopathy is frequently self-limiting.

Approximately 75% of patients improve spontaneously with nonsurgical treatment.

For this reason, conservative management is generally the initial treatment of choice when no progressive neurologic deficit or myelopathy is present.

Activity Modification

Relative rest and avoidance of activities that clearly worsen symptoms can be helpful during the acute phase.

Prolonged inactivity should be avoided because it may contribute to deconditioning and stiffness.

Soft Cervical Collar

A soft cervical collar may provide short-term symptomatic relief in acute cases by limiting painful motion.

Prolonged use is generally discouraged because it can lead to muscle weakness and dependence.

Physical Therapy

Physical therapy can address pain, mobility, strength, and return to function.

Treatment may initially include passive modalities, followed by stretching, postural work, strengthening, and progressive activity.

Cervical Traction

Cervical traction may reduce radicular symptoms in selected patients.

It can be performed under supervision in therapy or with an appropriate home device.

Its effectiveness varies among individuals.

Medication

Long-term maintenance opioid therapy has no established role in routine management of cervical disc herniation.

Medication should be directed toward short-term symptom control while the underlying condition is treated conservatively or surgically as appropriate.

First-Line Medication

Common first-line options include NSAIDs, acetaminophen, and selected anti-inflammatory agents when there are no contraindications.

Gastrointestinal, renal, cardiovascular, and other patient-specific risks should be considered.

Second-Line Treatment

Selected patients may be considered for cervical epidural corticosteroid injection.

Such injections may reduce radicular inflammation and pain, although they do not correct the structural disc herniation itself.

Indications for Surgical Referral

Surgical evaluation should be considered when symptoms fail to improve after approximately 6 weeks of appropriate conservative treatment, especially when pain remains disabling.

Earlier referral is indicated for progressive neurologic deficit, severe motor weakness, or signs of cervical myelopathy.

Surgery

Operative options include anterior cervical discectomy and fusion, posterior cervical foraminotomy, laminoplasty, and cervical disc arthroplasty.

The choice depends on the location of compression, cervical alignment, number of affected levels, patient age, and associated degenerative changes.

Anterior Cervical Discectomy and Fusion

Anterior cervical discectomy and fusion (ACDF) is a commonly used procedure for cervical radiculopathy.

It is particularly appropriate when the disc herniation is central or when there is associated kyphosis, axial neck pain, or anterior spinal cord compression.

Principles of ACDF

The affected disc is removed through an anterior approach.

The compressed nerve root or spinal cord is decompressed, after which the disc space is reconstructed and fused.

Instrumentation may be added depending on the level and pathology.

Posterior Cervical Foraminotomy

A posterior laminoforaminotomy or foraminotomy can be used for lateral or foraminal soft-disc herniations, particularly when arm pain predominates.

This approach can decompress the affected nerve root while preserving the intervertebral disc and motion segment in selected patients.

Laminoplasty

Laminoplasty is a motion-preserving posterior decompression procedure primarily used for multilevel cervical spinal cord compression in a lordotic cervical spine.

It may be an alternative to multilevel laminectomy and fusion or extensive anterior decompression in appropriately selected patients.

Cervical Disc Arthroplasty

Cervical total disc arthroplasty replaces the diseased disc with an artificial disc while preserving segmental motion.

For selected patients with single-level degenerative cervical radiculopathy, short- and intermediate-term outcomes can be comparable to those of ACDF.

Surgical Treatment of Myelopathy

The operative approach for cervical myelopathy depends on cervical alignment, number of involved levels, location of compression, previous surgery, and relevant medical conditions.

Anterior, posterior, or combined approaches may be required.

Follow-Up

Patients treated conservatively should be reassessed for improvement or progression of pain, weakness, numbness, gait disturbance, and fine-motor dysfunction.

Development of new myelopathic signs requires prompt reassessment.

Referral for Possible Shoulder Pathology

Shoulder disorders can closely mimic cervical radiculopathy.

When examination suggests intrinsic shoulder disease, referral to an orthopaedic or shoulder specialist may be appropriate.

Prognosis

The overall prognosis for cervical radiculopathy is generally favorable.

Population-based studies have shown that approximately 90% of patients can achieve satisfactory outcomes with either nonoperative or operative treatment.

Prognosis of Cervical Myelopathy

Surgery for cervical myelopathy frequently produces meaningful neurologic improvement or stabilization.

However, the degree of recovery depends heavily on the severity and duration of spinal cord compression.

Importance of Early Recognition

Early diagnosis and treatment of cervical myelopathy are important because prolonged spinal cord compression can produce irreversible neurologic injury.

Patients with moderate or severe myelopathy may continue to have residual neurologic deficits even after successful decompression.

Complications of Surgery

Potential complications include infection, persistent neurologic deficit, new neurologic deficit, worsening weakness, pseudarthrosis, adjacent-segment degeneration, dysphagia, and recurrent laryngeal nerve injury.

The complication profile varies with the surgical approach.

Surgical Infection

Posterior cervical procedures generally have a higher wound-infection risk than anterior approaches.

Careful soft-tissue handling and postoperative wound monitoring are therefore important.

C5 Palsy

A new postoperative C5 nerve-root palsy can occur after either anterior or posterior cervical decompression.

It typically produces deltoid and sometimes biceps weakness.

Many patients experience substantial functional recovery over time.

Dysphagia

Difficulty swallowing is common after anterior cervical surgery.

It usually improves gradually and often resolves within several months, although persistent symptoms may occasionally occur.

Pseudarthrosis

Failure of fusion, or pseudarthrosis, can cause persistent neck pain and may occasionally require revision surgery.

The risk is influenced by smoking, multilevel surgery, bone quality, and other patient factors.

Adjacent-Segment Degeneration

Degenerative changes may develop at levels adjacent to a cervical fusion over time.

Some degeneration reflects the natural history of cervical spondylosis, while altered biomechanics following fusion may also contribute.

Plate-Related Adjacent-Level Degeneration

Anterior plates positioned close to an adjacent disc space may contribute to accelerated degeneration or ossification at that level.

Appropriate implant positioning may reduce this risk.

Hoarseness

Hoarseness after anterior cervical surgery may result from injury or irritation of the recurrent laryngeal nerve.

Most cases improve, but persistent vocal changes can occasionally occur.

Patient Monitoring

Patients should be monitored for progressive weakness, worsening sensory loss, gait deterioration, loss of fine-motor control, bowel or bladder dysfunction, and other signs of spinal cord involvement.

Any progression of myelopathic symptoms should prompt urgent specialist evaluation.

Orthopaedic Surgery - Cerebral Palsy

Basics

Cerebral palsy is an umbrella term describing a broad group of permanent disorders of movement and posture caused by a static injury or abnormality of the developing central nervous system.

Although the underlying neurologic lesion itself is nonprogressive, its clinical consequences can change considerably as the child grows.

Muscle imbalance, contracture, skeletal deformity, altered gait, and functional limitations may therefore become more or less apparent over time even though the cerebral injury remains unchanged.

Classification

Cerebral palsy can be classified according to both the anatomic distribution of involvement and the physiologic pattern of motor abnormality.

A complete description should ideally include both components.

Anatomic Classification

Monoplegia affects one limb.

Hemiplegia involves the arm and leg on the same side of the body.

Diplegia predominantly affects both lower extremities.

Triplegia involves three extremities.

Quadriplegia involves all four extremities, with relatively preserved head control.

The term totally involved cerebral palsy is used for extensive involvement of all extremities accompanied by poor head and trunk control.

Physiologic Classification

The major physiologic patterns include spastic, athetoid, dystonic, and mixed cerebral palsy.

Spasticity is the most common motor abnormality.

Some patients demonstrate more than one movement pattern and are therefore classified as having mixed cerebral palsy.

Gross Motor Function Classification

The Gross Motor Function Classification System (GMFCS) is frequently used to describe functional mobility.

It assists with prognosis, communication among clinicians, and decision-making regarding operative and nonoperative treatment.

Functional classification is particularly useful because children with the same anatomic distribution of cerebral palsy may have very different levels of independence.

Epidemiology

Cerebral palsy affects approximately 2 per 1,000 live births.

Despite advances in obstetric and neonatal care, the overall prevalence has not shown a major decline.

Risk Factors

Important risk factors include prematurity, difficult delivery, multiple gestation, and postnatal injury to the central nervous system.

Several prenatal, perinatal, and postnatal events can ultimately produce the static cerebral lesion responsible for cerebral palsy.

Pathophysiology

Cerebral palsy produces predominantly upper motor neuron findings.

Peripheral nerves are generally anatomically normal.

The exact regions of the brain affected depend on the underlying cause and timing of the insult.

Muscle Changes

Although the primary lesion is neurologic, muscles in affected limbs can undergo secondary structural changes.

These include varying degrees of fibrosis, reduced muscle growth, shortening, and loss of normal excursion.

Such changes contribute to fixed contractures and progressive orthopaedic deformity.

Muscle biopsy is not routinely required.

Etiology

Potential causes include prenatal brain dysplasia, maternal infection, fetal hypoxia, vascular events, encephalitis, meningitis, trauma, and kernicterus.

In many patients, the precise causal event cannot be identified.

Associated Conditions

Cerebral palsy may coexist with a number of neurologic, developmental, and systemic conditions.

These include learning difficulties, behavioral disorders, abnormalities of sensory processing, visual impairment, hearing loss, seizures, and osteoporosis.

Respiratory and Gastrointestinal Disease

Children with severe cerebral palsy may also develop chronic respiratory and gastrointestinal problems.

Swallowing dysfunction, aspiration, gastroesophageal reflux, impaired cough, reduced mobility, and poor nutrition can contribute to these complications.

Diagnosis

Signs and Symptoms

One common early pattern is initial hypotonia followed later by increasing spasticity.

Developmental motor milestones may be delayed, and abnormal gait may become evident as walking begins.

Asymmetry of posture, limb use, strength, or gait may also be present.

Reflex Abnormalities

Deep tendon reflexes are often increased after the first year of life.

Clonus may develop in involved muscle groups.

Persistent primitive reflexes beyond the expected developmental period may also be observed.

Contractures

As children grow, contractures commonly develop in muscle groups exposed to persistent spasticity and reduced excursion.

The Achilles tendon, hamstrings, and hip adductors are especially prone to shortening.

Physical Examination

The examination should assess the child globally rather than focusing on a single joint or extremity.

Neurologic findings, muscle tone, mobility, joint motion, skeletal alignment, function, and independence in activities of daily living should all be considered.

Upper-Extremity Examination

The upper extremities should be examined for deformity, motor function, sensation, selective control, and practical use of the hands.

The ability to integrate sensation with motor function is especially important when considering reconstructive procedures.

Spine Examination

The spine should be examined for scoliosis, pelvic obliquity, and signs of spinal dysraphism.

Progressive spinal deformity is especially common in children with severe motor impairment.

Limb-Length Assessment

Limb lengths should be measured and compared.

Asymmetric growth may occur, especially in hemiplegic cerebral palsy.

Leg-length discrepancy can influence gait and pelvic alignment.

Joint Contractures

Range of motion should be measured systematically at all major joints.

Important measurements include ankle dorsiflexion, popliteal angle, and hip abduction.

These measurements help distinguish dynamic spasticity from established contracture.

Muscle Excursion

Muscle length and excursion should be documented.

Particular attention should be paid to the gastrocnemius-soleus complex, hamstrings, hip adductors, hip flexors, and rectus femoris.

Loss of excursion may indicate developing fixed deformity.

Dynamic Versus Fixed Deformity

The examiner should distinguish between dynamic spasticity, fixed soft-tissue contracture, bony torsional deformity, and joint instability.

This distinction is essential because each problem requires a different treatment strategy.

Gait Analysis

Instrumented and video gait analysis can provide detailed information about abnormal walking patterns.

It is particularly useful in ambulatory children with complex gait abnormalities.

Role of Instrumented Gait Analysis

Three-dimensional gait analysis may assist with planning single-event multilevel surgery (SEMLS).

It can identify the contribution of individual joints and muscle groups to the gait abnormality and can also help assess postoperative outcomes.

Imaging

Brain MRI

Most children clinically suspected of having cerebral palsy demonstrate abnormalities on brain imaging.

MRI is useful for identifying evidence of prior cerebral injury, malformation, hypoxic-ischemic damage, or other structural abnormalities.

However, a minority of children who meet clinical criteria for cerebral palsy may have a normal MRI.

Cervical Spine Imaging

Cervical spine radiographs may be indicated in selected patients with severe athetoid or dystonic movements.

Repeated involuntary neck motion can predispose some patients to cervical degeneration or instability.

Hip Radiographs

Routine surveillance radiographs of the hips are important in children with severe diplegia, quadriplegia, or total-body involvement.

These patients are at increased risk of progressive hip subluxation and dislocation.

Scoliosis Imaging

When clinical spinal deformity is present, standing or sitting scoliosis radiographs should be obtained as appropriate.

Children with severe motor impairment are particularly susceptible to progressive spinal curvature.

Differential Diagnosis

Conditions that may mimic cerebral palsy include brain or upper spinal cord tumors, upper cervical instability, neurodegenerative disorders, muscular dystrophies, metabolic disease, familial spastic paraparesis, early myopathy or neuropathy, and Rett syndrome.

Unlike cerebral palsy, many of these disorders are progressive.

Treatment

General Principles

Treatment does not correct the original cerebral lesion.

Management is therefore directed toward maximizing function, encouraging development, reducing spasticity, preventing contracture, and correcting secondary musculoskeletal deformity.

Early Stimulation

In infancy, stimulation and encouragement of movement are among the most important interventions.

Children should be given opportunities to develop motor skills, postural control, reaching, sitting, standing, and mobility according to their abilities.

Stretching

Muscle groups at risk of contracture should be stretched regularly.

The hamstrings and gastrocnemius-soleus complex commonly require particular attention.

Stretching is most useful for preserving existing range of motion rather than reversing a mature fixed contracture.

Physical Therapy

Physical therapy is most effective when directed toward specific and achievable short-term goals.

It can address gait training, mobility, stretching, strengthening, positioning, transfers, and use of adaptive equipment.

Therapists also help monitor changes in function over time.

Orthotics and Bracing

Orthoses may improve positioning, maintain range of motion, support standing or walking, and reduce deforming forces.

Ankle-foot orthoses are frequently used to improve foot position and assist gait.

Bracing should be individualized to functional goals.

Botulinum Toxin

Botulinum toxin injections can temporarily reduce focal spasticity.

They are particularly useful in younger children who are not yet appropriate candidates for definitive orthopaedic surgery.

Botulinum toxin may facilitate therapy, improve gait or positioning, and delay development of fixed contracture.

Intrathecal Baclofen

Intrathecal baclofen can reduce severe generalized spasticity by delivering medication directly into the spinal fluid.

It is used particularly in patients with widespread tone abnormalities, often in those who are nonambulatory.

Diazepam

Diazepam may reduce muscle spasm in selected circumstances but generally has limited long-term benefit.

It may occasionally be used around the time of surgery when temporary control of postoperative spasm is needed.

Multidisciplinary Care

Optimal management requires a multidisciplinary approach.

The treatment team may include physical therapists, occupational therapists, speech and language therapists, orthotists, dietitians, social workers, pediatricians, neurologists, rehabilitation specialists, and orthopaedic surgeons.

Occupational Therapy

Occupational therapy focuses on upper-extremity function, self-care, positioning, adaptive equipment, and activities of daily living.

Therapists may also assist with seating systems, communication strategies, and environmental adaptations.

Speech and Feeding Therapy

Speech and language specialists may address communication difficulties and swallowing dysfunction.

Feeding assessment is particularly important in children with severe cerebral palsy who are at risk of aspiration or inadequate nutrition.

Surgery

Surgical management is directed toward secondary effects of cerebral palsy rather than the original brain injury.

Procedures may include soft-tissue releases, tendon lengthening, selective dorsal rhizotomy, intrathecal baclofen pump placement, osteotomy, hip reconstruction, and scoliosis surgery.

Single-Event Multilevel Surgery

Single-event multilevel surgery (SEMLS) involves correcting several lower-extremity deformities during one operative episode.

Soft-tissue and bony procedures are combined according to the patient’s gait abnormalities.

The goal is to reduce the number of separate operations and consolidate rehabilitation into a single major recovery period.

Selective Dorsal Rhizotomy

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure designed to reduce spasticity at the spinal cord level.

Individual dorsal sensory rootlets are electrically tested, and those producing the most abnormal spastic responses are selectively divided.

Candidates for Selective Dorsal Rhizotomy

SDR is most commonly considered in younger ambulatory children with spastic diplegia, particularly those under approximately 10 years of age who have good underlying strength and selective motor control.

Only a small proportion of children improve by an entire GMFCS level after the procedure.

The primary goal is reduction of spasticity rather than transformation of baseline neurologic function.

Intrathecal Baclofen Pump

An intrathecal baclofen pump provides continuous medication to the spinal canal.

It is particularly useful for severe generalized spasticity or dystonia and is used more commonly in nonambulatory patients.

The pump requires long-term surveillance and periodic refilling.

Muscle Lengthening

Lengthening of contracted muscles can reduce abnormal triggering and allow improved joint positioning during gait.

Commonly treated structures include the Achilles tendon, hamstrings, hip adductors, and occasionally the rectus femoris.

Overlengthening should be avoided because it may create weakness.

Foot Deformities

Significant foot deformity should generally be corrected when it interferes with standing, shoe wear, bracing, or walking.

Even children with limited ambulatory potential may benefit from a plantigrade, braceable, and pain-free foot.

Upper-Extremity Surgery

Surgery for upper-extremity muscle imbalance is undertaken selectively.

Outcomes may be less predictable when sensory integration and selective motor control are poor.

For this reason, hand surgery is less commonly beneficial than lower-extremity reconstruction in severely involved patients.

Hip Subluxation

Progressive hip displacement should ideally be treated before degenerative changes and severe pain develop.

Hip surveillance is therefore a critical component of long-term management.

Adductor Lengthening

Early hip migration caused partly by adductor contracture may be treated with adductor muscle lengthening in selected children.

The goal is to reduce deforming forces and maintain hip containment.

Femoral and Pelvic Osteotomy

More advanced hip subluxation may require a femoral osteotomy, often combined with a pelvic osteotomy.

These procedures restore alignment and improve containment of the femoral head within the acetabulum.

Salvage Hip Procedures

When severe chronic hip dislocation has already produced major pain and joint destruction, reconstructive surgery may no longer be possible.

Rarely, salvage procedures such as femoral head resection may be considered to relieve pain and improve sitting or hygiene.

Scoliosis

Progressive scoliosis can interfere with sitting balance, comfort, pulmonary function, skin care, and mobility.

Treatment depends on curve severity, growth, functional status, and symptoms.

Bracing for Scoliosis

A spinal brace may improve sitting comfort and support in selected patients.

However, bracing generally does not reliably prevent progression of neuromuscular scoliosis.

Scoliosis Surgery

Children with severe progressive curves causing poor sitting balance, pain, or functional difficulty may benefit from spinal correction and fusion.

The aim is to create a stable, balanced trunk and improve comfort and care.

Follow-Up

Children with cerebral palsy should generally be reviewed by an orthopaedic team at least once each year during growth.

Those with more severe involvement or known progressive deformity may require more frequent assessment.

Importance of Surveillance

Regular monitoring allows early detection of hip dysplasia, contracture, scoliosis, foot deformity, and declining function.

Treatment is often more effective when abnormalities are identified before they become fixed or painful.

Prognosis

Prognosis depends primarily on the severity and distribution of cerebral palsy and associated medical conditions.

Patients with extensive total-body involvement may have reduced life expectancy because of respiratory, nutritional, and other systemic complications.

Individuals with less severe forms may have a life expectancy close to that of the general population.

Walking Ability

Many ambulatory children experience some decline in walking efficiency near skeletal maturity.

Walking with cerebral palsy often requires substantially more energy than normal gait.

As body size and weight increase, this energy demand can make community ambulation more difficult.

Complications

Potential complications include progressive joint contracture, hip displacement, scoliosis, foot deformity, reduced mobility, osteoporosis, fractures, obesity, respiratory disease, and gastrointestinal dysfunction.

The pattern varies considerably according to GMFCS level and overall severity.

Weight Gain

Excessive weight gain can further impair mobility and increase the energy cost of walking or transfers.

At the same time, some severely affected patients may have poor nutritional intake.

Nutrition therefore requires careful individualized monitoring.

Fractures and Osteoporosis

Nonambulatory patients are at increased risk of low bone mineral density and fractures.

Reduced weight-bearing, nutritional deficiencies, anticonvulsant use, and limited mobility may all contribute.

Respiratory Complications

Children with severe total-body involvement are more prone to chronic respiratory problems.

Aspiration, weak cough, recurrent infection, scoliosis, and reduced mobility can impair pulmonary function.

Gastrointestinal Complications

Gastroesophageal reflux, constipation, swallowing dysfunction, and feeding difficulties are common in more severely affected children.

These problems can contribute to poor growth and recurrent respiratory illness.

Patient Monitoring

Children should be assessed periodically for functional mobility, gait, joint range of motion, muscle tone, hip stability, spinal alignment, and independence in activities of daily living.

At minimum, yearly review during growth is appropriate, with closer surveillance when progressive deformity or functional decline is present.

Orthopaedic Surgery - Cavus Foot

Basics

Cavus foot is characterized by an abnormally elevated medial longitudinal arch, often accompanied by deformity of the hindfoot, forefoot, or both.

The deformity may be flexible in its early stages but can gradually become rigid as secondary soft-tissue contractures and bony changes develop.

Epidemiology

Cavus feet are relatively common and may occur in otherwise healthy individuals or as a manifestation of an underlying neurologic or musculoskeletal disorder.

Approximately 10% of the healthy population may demonstrate some degree of cavus foot.

A substantial proportion of clinically significant cases, historically estimated at approximately 80%, are associated with an underlying neurologic disorder.

Risk Factors

Important risk factors include neuromuscular disease, previous trauma, connective tissue disorders, and congenital deformities.

Any condition that creates chronic imbalance between the muscles acting across the foot and ankle can contribute to development of a cavus deformity.

Genetics

Several disorders responsible for cavus foot are hereditary.

The most common inherited cause is Charcot-Marie-Tooth disease, also known as hereditary motor and sensory neuropathy.

The classic form of Charcot-Marie-Tooth disease is often inherited in an autosomal dominant pattern.

Pathophysiology

Neuromuscular disease is the most common underlying cause of clinically significant cavus deformity.

Abnormal muscle strength and imbalance can produce progressive muscle atrophy, fibrosis, deformity, and joint contracture.

The deformity often begins as a flexible abnormality during childhood or adolescence and gradually becomes more rigid with growth and progression of the underlying disease.

Muscle Imbalance

Different patterns of muscle imbalance can produce different forms of cavus foot.

Excessive pull from the peroneus longus or posterior tibialis may contribute to abnormal plantarflexion or inversion forces.

Weakness of the intrinsic foot muscles can allow the long flexor tendons to dominate, resulting in clawing of the toes and progressive forefoot deformity.

Connective Tissue Disorders

Connective tissue abnormalities may also contribute to cavus foot.

Conditions such as Marfan syndrome can alter the structural support and mechanical balance of the foot.

Associated Conditions

The underlying cause should be investigated because cavus foot may be the first indication of a neurologic disorder.

The differential diagnosis differs depending on whether the deformity is bilateral or unilateral.

Bilateral Cavus Foot

Bilateral cavus deformity is commonly associated with generalized or hereditary neurologic disease.

Important causes include Charcot-Marie-Tooth disease, Friedreich ataxia, syringomyelia, myelomeningocele, muscular dystrophy, spinal cord tumor, and polyneuritis.

Unilateral Cavus Foot

A unilateral cavus deformity should raise concern for a focal neurologic or traumatic cause.

Potential etiologies include previous poliomyelitis, prior compartment syndrome of the leg or foot, traumatic peripheral nerve injury, spinal nerve root injury, severe burns, and spinal cord tumors.

A new unilateral deformity warrants particularly careful neurologic investigation.

Diagnosis

Signs and Symptoms

The characteristic finding is a high medial longitudinal arch.

Patients may also develop calluses beneath the forefoot or heel because of abnormal pressure distribution.

Some individuals remain asymptomatic, while others have pain, difficulty fitting shoes, instability, or progressive deformity.

Hindfoot Varus

The heel may be positioned in varus, causing the patient to bear excessive weight along the lateral border of the foot.

Marked hindfoot varus can predispose to recurrent lateral ankle sprains and chronic ankle instability.

Plantarflexed First Ray

A relatively plantarflexed first metatarsal or first ray is common.

This can drive the hindfoot into varus during weight-bearing and is important when distinguishing a flexible from a fixed hindfoot deformity.

Metatarsalgia

Patients may develop metatarsalgia, particularly beneath the metatarsal heads.

The elevated arch and altered forefoot loading produce excessive plantar pressure and can lead to painful callus formation.

Shoe-Wear Difficulty

Rigid or severe cavus deformity may make conventional footwear uncomfortable.

Prominent metatarsal heads, claw toes, a high instep, or lateral foot overload can create pressure points and skin irritation.

Ankle Instability

Severe cavovarus alignment increases the tendency for the ankle to invert.

Patients may therefore experience recurrent ankle sprains or chronic lateral ankle instability.

History

A complete birth, developmental, neurologic, and medical history is essential when evaluating cavus foot.

The clinician should determine when the deformity was first noticed, whether it is progressing, and whether symptoms such as weakness, numbness, gait disturbance, or balance difficulty are present.

Family History

A family history of cavus foot, neuropathy, gait abnormalities, or muscle weakness should be explored.

A positive family history may suggest an inherited disorder such as Charcot-Marie-Tooth disease.

Tethered Cord Consideration

A sudden increase in cavus deformity in a child with myelomeningocele or lipomeningocele may indicate tethering of the spinal cord.

Progressive deformity in this setting warrants neurologic and spinal evaluation.

Physical Examination

The examination should assess the entire lower extremity rather than the foot alone.

Motor strength of all muscles crossing the ankle should be measured bilaterally.

The pattern of weakness may provide clues regarding the underlying neurologic disorder.

Toe Deformities

Associated claw-toe deformities should be identified.

These often result from intrinsic muscle weakness and relative overpull of the long toe flexors and extensors.

Plantar Fascia

The plantar fascia should be assessed for tightness or contracture.

A shortened plantar fascia can help maintain the elevated arch and may contribute to rigidity of the deformity.

Neurologic Examination

Reflexes and sensation to light touch should be evaluated carefully.

Reduced reflexes, sensory loss, or distal weakness may indicate peripheral neuropathy.

Upper-Extremity Examination

The upper extremities should also be examined, particularly for intrinsic hand muscle wasting.

This can provide additional evidence of a generalized hereditary neuropathy such as Charcot-Marie-Tooth disease.

Spine Examination

The spine should be inspected for scoliosis, dimples, skin markings, hairy patches, or other abnormalities that may indicate occult spinal dysraphism or another spinal disorder.

Coleman Block Test

The Coleman block test helps determine whether hindfoot varus is flexible or rigid.

The patient stands with the heel and lateral border of the foot supported on a block while the first metatarsal and great toe hang freely off the edge.

Principle of the Coleman Block Test

Allowing the first ray to drop freely removes the effect of a plantarflexed first metatarsal on hindfoot alignment.

If the hindfoot varus corrects toward neutral, the deformity is considered flexible and forefoot-driven.

Rigid Hindfoot Varus

If the hindfoot remains in varus despite unloading the first ray, the deformity is considered rigid.

A rigid deformity is more likely to require a bony corrective procedure rather than soft-tissue treatment alone.

Electrodiagnostic Studies

Electromyography and nerve conduction studies may assist in diagnosing Charcot-Marie-Tooth disease, hereditary motor and sensory neuropathies, and lumbar radiculopathy.

These tests can characterize the distribution and severity of nerve dysfunction.

Imaging

Weight-Bearing Radiographs

Standing radiographs of the foot should be obtained to evaluate alignment and the severity of deformity.

Two useful measurements are the calcaneal pitch angle and the Meary angle.

Calcaneal Pitch

The calcaneal pitch is the angle between the inferior surface of the calcaneus and the floor.

An increased calcaneal pitch supports the presence of a high-arched cavus foot.

Meary Angle

The Meary angle is formed by the longitudinal axes of the talus and first metatarsal.

Abnormal angulation reflects disruption of normal longitudinal alignment and helps characterize the location and severity of the cavus deformity.

Spinal Imaging

When the cause of cavus foot is uncertain, radiographs or MRI of the spine may be indicated.

These studies can identify occult spinal cord abnormalities, tumors, tethering, or other neurologic causes.

Differential Diagnosis

Muscle wasting can sometimes make the longitudinal arch appear unusually high even when a true structural cavus deformity is not present.

The clinician should distinguish apparent high arch from fixed bony or soft-tissue deformity.

Treatment

General Measures

No treatment is required when the patient is asymptomatic, functionally normal, and has healthy skin without pressure lesions.

Management is directed toward symptoms, progression, instability, and the underlying cause.

Insoles and Metatarsal Support

A padded insole with an arch support or metatarsal bar may reduce plantar pressure and relieve metatarsalgia.

The orthosis should redistribute pressure rather than excessively increase an already high arch.

Lateral Heel Wedge

A lateral heel wedge may help correct a flexible hindfoot varus deformity by encouraging the heel toward a more neutral position.

It is most effective when the hindfoot remains passively correctable.

Bracing

A brace may be useful when significant muscle weakness produces instability.

Bracing can also help patients who have both cavus deformity and chronic ankle instability.

Stretching

Regular stretching may help maintain flexibility and slow the development of fixed contractures.

Particular attention may be given to the plantar fascia and other tight muscle-tendon units.

Orthoses

Custom-made foot orthoses can reduce pain in patients with cavus feet from a variety of causes.

They are particularly useful for redistributing abnormal plantar pressures and improving shoe tolerance.

Cavovarus Deformity

Cavovarus feet are often less well tolerated than isolated mild cavus feet.

Progressive deformity may lead to shoe-wear difficulty, recurrent ankle instability, painful calluses, metatarsalgia, and eventually arthritis.

Physical Therapy

Physical therapy may include stretching of the plantar fascia and other contracted muscles or tendons.

The goal is to preserve flexibility and slow progression toward a rigid deformity.

Strengthening and Proprioception

When ankle instability is present, strengthening, proprioceptive training, and closed-chain balance exercises may be helpful.

These exercises improve dynamic control of the ankle but do not correct a fixed structural cavovarus deformity.

Indications for Surgery

Surgery is usually considered for progressive deformity, persistent pain despite conservative treatment, chronic ankle instability, major shoe-wear difficulty, or rigid deformity associated with arthritis.

The procedure must be tailored to the specific components of the deformity.

Surgical Planning

Careful examination is required to determine which portions of the deformity are flexible and which are fixed.

Surgical treatment is usually stepwise and individualized, with correction of muscle imbalance, soft-tissue contracture, bony malalignment, and instability as needed.

Flexible Deformity

Flexible deformities can often be treated primarily with soft-tissue rebalancing procedures.

These may include tendon transfer, tendon lengthening, or plantar fascia release.

Rigid Deformity

Rigid deformities generally require osteotomy or arthrodesis because soft-tissue procedures alone cannot adequately correct fixed bony alignment.

The goal is to restore a plantigrade, stable, and pain-free foot.

Plantar Fasciotomy

A plantar fasciotomy may be used to release a contracted plantar fascia and help lower the excessively high arch.

It is often performed as one component of a larger reconstruction.

Midfoot and Metatarsal Osteotomies

Rigid cavus deformity may require midfoot or metatarsal osteotomies.

These procedures correct fixed bony angulation and redistribute plantar loading.

Calcaneal Osteotomy

When hindfoot varus is rigid, a lateral closing-wedge calcaneal osteotomy may be performed.

This repositions the heel into a more neutral alignment and reduces excessive loading along the lateral border of the foot.

Tendon Lengthening

Contracted muscle-tendon units may require surgical lengthening.

This decreases deforming forces and improves balance around the foot and ankle.

Tendon Transfers

Tendon transfers are commonly used when muscle imbalance is a major component of the deformity.

A functioning tendon is redirected to compensate for a weak muscle group and restore more balanced forces across the foot.

Chronic Ankle Instability

When chronic ligamentous instability accompanies cavovarus deformity, lateral ligament reconstruction may be required.

Correction of the cavovarus alignment is usually important as well, because ligament reconstruction alone may fail if the underlying varus deformity remains.

Tenodesis procedures may sometimes be added for additional stabilization.

Complex or Previously Operated Feet

Stiff or multiply operated cavus feet may require more extensive reconstruction.

Procedures such as navicular excision or cuboid closing-wedge osteotomy may be used in selected complex cases.

Triple Arthrodesis

Triple arthrodesis is generally reserved as a salvage procedure.

It may be indicated when previous reconstruction has failed or when the patient has a rigid deformity with painful arthritis involving multiple hindfoot joints.

Follow-Up

Patients with cavus foot should be followed periodically by an orthopaedic specialist, particularly when the deformity is progressive or associated with muscle weakness.

Monitoring should assess alignment, muscle strength, sensory status, skin integrity, ankle stability, and progression of contractures.

Timing of Reconstruction

Progressive deformity may be easier to correct before it becomes completely rigid.

Early recognition and reconstruction in selected patients may avoid the need for later fusion procedures.

Indications for Referral

All patients with symptomatic cavus feet should be considered for orthopaedic evaluation.

Referral is especially important when the deformity is unilateral, progressive, associated with neurologic signs, or causing recurrent instability or skin problems.

Prognosis

Cavus feet caused by an underlying neuropathy often progress gradually over time.

The rate and severity of progression depend on the underlying neurologic disease and the degree of muscle imbalance.

Neuropathic Ulceration

Patients with diabetes or Charcot-Marie-Tooth disease may lose protective sensation.

Abnormal pressure beneath prominent parts of the foot can then produce neuropathic ulceration.

Repeated ulceration may progress to infection and osteomyelitis.

Risk of Amputation

Severe neuropathic ulceration complicated by deep infection or osteomyelitis can eventually result in amputation.

For this reason, appropriate footwear, orthoses, routine skin inspection, and pressure reduction are especially important in patients with sensory loss.

Footwear in Athletes

For athletes with cavus feet, neutral cushioned running shoes may help reduce plantar pressures and lower the risk of repetitive pressure-related injury.

Footwear should be selected according to comfort, alignment, and the individual’s activity demands.

Patient Monitoring

Patients should be monitored for progressive arch elevation, increasing hindfoot varus, muscle weakness, sensory loss, recurrent ankle sprains, painful calluses, and skin ulceration.

Any rapid change in deformity or neurologic function should prompt investigation for an underlying or worsening neurologic disorder.

Here is the paraphrased version in the same format, with “Orthopaedic Surgery -” added at the beginning of the title.

Orthopaedic Surgery - Casts and Splints

Basics

Casts and splints are used to immobilize injured bones and joints, reduce pain, maintain alignment, and protect healing tissues.

Because casts completely surround the limb and do not readily accommodate acute swelling, most newly injured extremities are initially treated with a splint rather than a circumferential cast.

Splints allow more room for swelling and therefore reduce the risk of pressure-related complications, including iatrogenic compartment syndrome.

Emergency Splinting

In the field, almost any rigid material can be used temporarily as a splint.

Examples include wooden slats, sticks, cardboard, or pillows.

Whatever material is used, adequate padding should be placed between the splint and the skin to protect the soft tissues and prevent pressure injury.

Principles of Immobilization

When a fracture is splinted, the injured bone should be immobilized together with the joint above and the joint below the fracture whenever possible.

This reduces movement at the fracture site and improves stability.

The limb should generally be positioned in a functional and comfortable alignment.

Casting and Splinting Materials

In hospitals and clinics, the two most common materials used for casts and splints are plaster of Paris and fiberglass.

Each has specific advantages and disadvantages.

Plaster of Paris

Plaster of Paris consists of muslin material stiffened with dextrose or starch and impregnated with calcium sulfate hemihydrate.

When water is added, the calcium sulfate crystallizes through an exothermic reaction, releasing heat as the material hardens.

Plaster generally sets within approximately 15 minutes.

Advantages of Plaster

Plaster is highly moldable and allows careful contouring around the extremity.

Its relatively slower setting time gives the clinician more time to apply three-point molding and fracture correction.

This makes plaster particularly useful when precise molding is required.

Fiberglass

Fiberglass is a more modern casting material made from a fiberglass substrate coated with a polyurethane resin.

The resin is activated by moisture and polymerizes as the material hardens.

Fiberglass generally becomes rigid within approximately 7 minutes and is lighter than plaster.

Disadvantages of Fiberglass

Fiberglass can be sticky and difficult to remove if it contacts uncovered skin.

Protective gloves should be used during application.

Its rapid hardening time may also make careful molding more difficult compared with plaster.

Pathophysiology

After musculoskeletal injury, damaged bone and soft tissues release inflammatory mediators, including substances such as interleukin-6.

Movement at an unstable fracture site can increase inflammation, pain, and additional muscle or soft-tissue injury.

Immobilization limits movement between fracture fragments and reduces mechanical irritation.

This generally decreases pain and allows inflammation to gradually settle.

Diagnosis

History

Patients requiring splinting or casting commonly present after trauma with a suspected or confirmed fracture, dislocation, or significant soft-tissue injury.

The mechanism of injury and timing should be documented.

Physical Examination

Before applying any splint or cast, the entire injured extremity should be examined carefully.

The clinician should look for open wounds or open fractures, which may require urgent surgical irrigation and debridement.

Joint Assessment

Nearby joints should be assessed for evidence of dislocation, instability, or additional injury.

Associated injuries can be overlooked if the examination focuses only on the obvious fracture.

Neurovascular Examination

A thorough neurovascular examination should be performed before immobilization.

Motor function, sensation, distal pulses, capillary refill, and skin temperature should be documented.

This provides a baseline for comparison after the splint or cast has been applied.

Swelling and Compartment Syndrome

The limb should also be inspected for swelling, tense compartments, severe pain, or neurologic changes that may indicate compartment syndrome.

Significant swelling influences the choice between a splint and a cast.

Imaging

Painful bones or joints following trauma should generally be assessed with appropriate plain radiographs when fracture or dislocation is suspected.

Imaging should be obtained according to the anatomical region and mechanism of injury.

Treatment

General Principles

During the acute period after injury, a splint is usually preferred because it can accommodate swelling.

After the initial swelling has subsided, a circumferential cast may be applied when longer-term rigid immobilization is required.

Timing of Casting

Many fractures are converted from a splint to a cast approximately 1–2 weeks after injury, once swelling has decreased.

The exact timing depends on the injury, swelling, skin condition, and fracture stability.

Immediate Cast Application

If a circumferential cast must be applied soon after an acute injury, it should generally be split, univalved, or bivalved to allow expansion.

The outer wrapping should remain relatively loose until swelling has stabilized.

Padding

The extremity must be well padded before application of either a splint or cast.

Additional protection should be placed over bony prominences, where pressure injury is most likely to occur.

Felt may be added in vulnerable areas when necessary.

Jewelry Removal

All rings, bracelets, watches, and other constricting jewelry should be removed from the injured extremity before swelling worsens.

Failure to remove jewelry can result in vascular compromise or skin injury.

Position of Function

Whenever possible, the injured limb should be immobilized in a functional position.

This helps minimize stiffness and preserves the ability to use the limb after immobilization is discontinued.

Water Temperature

Very hot water should not be used when activating plaster or fiberglass.

Because setting is an exothermic reaction, excessively warm water may increase heat production and cause a thermal burn beneath the cast or splint.

Avoiding Pressure Points

The clinician should avoid pressing fingertips directly into wet casting material.

Finger indentations may create focal pressure points that can lead to skin breakdown.

The palm of the hand should be used for molding whenever possible.

Three-Point Molding

Three-point fixation or molding is an important principle of fracture immobilization.

Pressure is applied at three carefully selected points to maintain reduction and resist deforming forces.

Proper molding improves fracture stability without creating excessive local pressure.

Open Fractures

Open fractures require urgent operative management but should still be temporarily splinted before surgery.

Immobilization decreases pain, prevents further soft-tissue damage, and protects the wound during transport.

Upper-Extremity Splinting

Proximal Humerus and Humeral Shaft Fractures

For fractures of the proximal humerus or humeral shaft, plaster support may be placed around the shoulder and along both sides of the arm.

A sling is commonly added for comfort and support.

A removable pad may be placed in the axilla so that the skin can be cleaned and the padding replaced as needed.

Humeral Fracture Brace

Once a humeral shaft fracture begins to stabilize, a functional fracture brace may be used.

This allows controlled movement while maintaining circumferential support of the humerus.

Elbow Injuries

The elbow is commonly splinted at approximately 90° of flexion, unless the specific injury requires another position.

Generous padding and a posterior slab are typically used.

A lateral slab may be added for reinforcement.

Hand Position With Elbow Splints

The splint should support the wrist but ideally leave the hand and fingers free when possible.

Once swelling has subsided, an above-elbow cast may be applied if longer immobilization is required.

Forearm and Wrist Injuries

A sugar-tong splint is frequently used for forearm and wrist injuries.

It extends around the elbow with the elbow flexed to approximately 90° and controls both wrist motion and forearm rotation.

MCP Joint Freedom

When applying forearm or wrist splints, the metacarpophalangeal joints should remain free whenever the injury permits.

This allows finger motion and reduces the risk of stiffness.

Below-Elbow Casts

Below-elbow casts should generally allow free movement of the fingers and thumb.

The cast should end proximal enough to avoid restricting the MCP joints unnecessarily.

Hand and Finger Injuries

An ulnar gutter splint, sometimes called a boxer splint, is commonly used for fractures involving the fourth and fifth metacarpals.

The splint is applied along the ulnar aspect of the hand and forearm, creating a supportive gutter.

Ulnar Gutter Splint Technique

A strip of plaster may extend from the tip of the fifth finger to a point approximately 2 inches distal to the antecubital fossa.

Padding or gauze is placed between the fourth and fifth fingers to prevent skin maceration.

Position for Ulnar Gutter Splint

The wrist is usually positioned in approximately 25–30° of extension.

The MCP joints are commonly flexed to approximately 90°, placing the hand in an intrinsic-plus position.

Finger Splints

Individual finger fractures may be immobilized using malleable aluminum finger splints.

These consist of soft aluminum lined with foam and can be cut and shaped to fit the involved digit.

Lower-Extremity Splinting

Femur and Hip Injuries

A Thomas splint is a premade traction splint that may be used temporarily for femoral injuries.

It includes a proximal ring and a longitudinal frame that allows traction to be applied to the leg.

Thomas Splint Sizing

The proximal ring should be approximately 2 inches larger than the circumference of the proximal thigh.

The ring rests against the ischial region and provides countertraction.

Traction Mechanism

A distal strap or ankle hitch is attached to the end of the splint to apply longitudinal traction.

This can temporarily reduce pain, shortening, and movement at the femoral fracture site.

Duration of Thomas Splint Use

A Thomas splint should not remain in place for prolonged periods.

Use beyond approximately 2 hours may place excessive pressure around the ankle hitch and can cause skin injury or necrosis.

Knee and Tibial Injuries

Injuries involving the knee or tibia may be immobilized using an above-knee splint extending to the foot.

The ankle should generally be maintained at approximately 90°.

Padding Around the Knee and Ankle

Special attention should be given to padding around the fibular head and peroneal nerve region, as well as around the malleoli and other ankle prominences.

Poor padding can result in nerve compression or pressure ulceration.

Above-Knee Cast

For stable fractures requiring prolonged immobilization, an above-knee cast may be applied once acute swelling has subsided sufficiently.

Ankle and Foot Injuries

Below-knee splints often combine a posterior slab and a U-shaped stirrup around the ankle.

This configuration provides support while still allowing some accommodation for swelling.

Ankle Position

The ankle should normally be held at approximately 90° of dorsiflexion.

This reduces the risk of developing an equinus position or Achilles tendon contracture.

Below-Knee Casts

Below-knee casts require careful padding, particularly around the malleoli, heel, and anterior tibia.

Pressure over these regions can quickly produce skin breakdown.

Ankle Air Splints

Less severe or more stable ankle injuries may be treated with a removable air-stirrup or ankle air splint.

These provide support while allowing more mobility than a rigid cast.

Activity

Patients should be encouraged to move joints that are not included within the cast or splint.

Maintaining motion helps reduce stiffness, swelling, and muscle weakness.

Joints Prone to Stiffness

The shoulder, elbow, hand, and fingers can become stiff particularly quickly.

Active movement of uninvolved joints should therefore begin as soon as it is safe.

Nursing and Neurovascular Monitoring

After application, the limb should be reassessed to ensure that the splint or cast is not excessively tight.

A repeat neurovascular examination should document motor function, sensation, perfusion, and distal pulses or capillary refill.

Medication

Patients with fractures may require significant pain control during the acute period.

Short-term opioid analgesics may sometimes be necessary, particularly with displaced or high-energy fractures.

Analgesic requirements usually decrease as the injury is stabilized and swelling subsides.

Surgery

Open, intra-articular, unstable, or significantly displaced fractures may require operative fixation.

Splinting is still useful as temporary stabilization while definitive surgical planning is completed.

Follow-Up

Patients with fractures treated initially in a splint should generally be referred to an orthopaedic specialist.

Follow-up commonly occurs within approximately 1 week to reassess alignment, swelling, and the need for surgical treatment.

Serial Radiographs

Fracture reduction and healing should be monitored with repeat radiographs when clinically indicated.

Imaging helps confirm that alignment has been maintained and that fracture union is progressing appropriately.

Complications

Excessively Tight Cast or Splint

A cast or splint may become too tight as swelling increases.

Persistent pain, pressure, numbness, tingling, or a sensation that the cast is constricting should prompt urgent reassessment.

Initial Response to Tightness

If excessive compression is suspected, the splint or cast should be loosened or split promptly.

The limb should then be reexamined to determine whether symptoms improve.

Compartment Syndrome

Persistent severe pain despite loosening should raise concern for compartment syndrome.

The splinting material should be opened completely so that the extremity can be examined.

Pressure Measurements

When the diagnosis remains uncertain, intracompartmental pressure measurements may be obtained.

Elevated pressures in the appropriate clinical setting support the diagnosis of compartment syndrome.

Fasciotomy

Confirmed compartment syndrome requires urgent surgical fasciotomy.

Delayed treatment can result in irreversible muscle and nerve injury and permanent loss of limb function.

Skin Breakdown

Pressure-related skin injury is another important complication.

Adequate padding over bony prominences and careful cast molding help prevent ulcers, abrasions, and skin necrosis.

Patient Monitoring

Patients should be monitored for increasing swelling, worsening pain, neurovascular changes, and signs of compartment syndrome.

Cast or splint fit should be reassessed as swelling changes.

Monitoring Fracture Alignment

Serial radiographs may be required until healing is sufficient to ensure that the fracture has not displaced.

The frequency of imaging depends on fracture type, stability, age, and treatment method.

Patient Teaching

After application of a cast or splint, patients should receive clear instructions regarding warning signs and care of the immobilization device.

They should understand when to seek urgent medical attention.

Warning Signs of Compression

Patients should immediately report increasing pain, numbness, tingling, weakness, excessive swelling, or a feeling that the splint or cast is becoming too tight.

These symptoms may indicate nerve compression, vascular compromise, or compartment syndrome.

Keeping the Splint or Cast Dry

The immobilization device should be kept dry unless it is specifically designed to tolerate water.

Moisture can weaken plaster, irritate the skin, and promote skin breakdown.

Problems With the Cast or Splint

Patients should contact their clinician if the cast becomes loose, cracked, wet, damaged, excessively tight, or painful.

Objects should never be inserted beneath the cast to scratch the skin.

Elevation

During the first 2–3 days, the injured limb should be elevated above the level of the heart whenever possible.

Elevation reduces swelling and pressure within the splint.

Weight-Bearing Restrictions

Patients should follow all prescribed weight-bearing restrictions.

Premature loading may cause loss of fracture reduction, implant failure, or delayed healing.

Exercising Free Joints

Joints not incorporated into the splint or cast should be moved regularly.

Finger or toe movement also helps reduce swelling and preserve mobility.

Frequently Asked Question: Can the Splint Be Removed?

In general, the splint should remain in place unless a clinician removes it for a more detailed examination or replaces it with another device.

Splints usually do not need to be removed for radiographs unless metal components interfere with the images.

If that occurs, a radiolucent alternative can be used.

Frequently Asked Question: Why Is a Cast Not Applied Immediately?

A cast surrounds the entire limb and does not accommodate acute swelling well.

A splint supports only part of the circumference and therefore allows more space for swelling.

For this reason, acute injuries are usually splinted first and converted to a cast after swelling has decreased.

If a splint itself feels excessively tight, it should also be reassessed and loosened promptly.

Orthopaedic Surgery - Carpal Tunnel Syndrome

Basics

Carpal tunnel syndrome (CTS) is a compressive neuropathy of the median nerve as it passes through the carpal tunnel at the wrist.

The carpal tunnel is a relatively rigid anatomical space. Its floor is formed by the volar radiocarpal and intercarpal ligaments, while the transverse carpal ligament forms the roof.

Within the tunnel pass nine flexor tendons—the four flexor digitorum profundus tendons, four flexor digitorum superficialis tendons, and the flexor pollicis longus tendon—together with the median nerve.

Because there is little room for expansion, any increase in pressure within the tunnel may compress the median nerve.

Functional Effects

Compression of the median nerve may cause numbness, paresthesias, pain, weakness, and impaired fine motor function.

Sensory symptoms usually involve the palmar surface of the thumb, index finger, middle finger, and radial half of the ring finger.

With more advanced compression, weakness or atrophy of the thenar muscles may develop, particularly affecting thumb palmar abduction.

Pregnancy Considerations

Carpal tunnel syndrome occurs more frequently during pregnancy than in the general population.

Symptoms commonly improve or resolve after delivery as pregnancy-related fluid retention decreases.

Initial treatment generally consists of a nighttime wrist splint maintaining the wrist in neutral.

A corticosteroid injection may be considered for persistent symptoms when appropriate, with medication safety reviewed in conjunction with the patient’s obstetric care.

Surgery During Pregnancy

Because pregnancy-related CTS frequently resolves postpartum, surgery is generally deferred when possible.

However, severe cases involving persistent numbness, progressive weakness, or major functional impairment may occasionally require surgical decompression during pregnancy.

When necessary, carpal tunnel release can be performed using local anesthesia.

Epidemiology

Carpal tunnel syndrome affects approximately 4–5% of the population.

It occurs most frequently between approximately 40 and 60 years of age and is more common in women than men.

CTS is the most frequently diagnosed compressive neuropathy of the upper extremity.

Risk Factors

Recognized risk factors include female sex, diabetes mellitus, hypothyroidism and other endocrine abnormalities, smoking, elevated body mass index, pregnancy, perimenopausal status, rheumatoid arthritis, and previous hand or wrist tendinopathy.

Forceful repetitive hand use may also contribute.

The relationship between CTS and routine computer use remains controversial.

Occupational Factors

Work involving forceful gripping, sustained wrist positioning, repetitive hand exertion, or vibration may increase symptoms in susceptible individuals.

In occupational cases, modification of the provoking activity can be an important part of treatment.

Genetics

No specific genetic factor has been definitively established as a direct cause of carpal tunnel syndrome.

However, inherited differences in anatomy, body habitus, and systemic disease susceptibility may indirectly influence risk.

Pathophysiology

CTS develops when increased pressure within the carpal tunnel compromises the median nerve.

Compression and traction can impair the nerve’s microcirculation, producing edema and reduced oxygen delivery.

Repeated or prolonged compression may subsequently produce recurrent demyelination and slower nerve conduction.

Nerve Conduction Changes

As compression becomes more severe, electrical impulses travel more slowly through the median nerve at the wrist.

Prolonged compression may eventually cause axonal injury, resulting in persistent numbness, weakness, and thenar muscle atrophy.

Etiology

Any process that reduces the available space within the carpal tunnel or increases its contents can compress the median nerve.

In many patients, no single structural cause is identified.

Common Causes

Potential causes include flexor tenosynovitis, previous trauma involving the carpal bones, ganglion cysts, fibromas, lipomas, rheumatoid cysts, gout, and diabetic neuropathy.

Inflammatory swelling of the tendon sheaths may be particularly important because all nine flexor tendons pass through the same confined space.

Diagnosis

Carpal tunnel syndrome can often be diagnosed accurately through a careful history and physical examination.

Evaluation should include assessment for sensory disturbance, thenar weakness or atrophy, and reproduction of symptoms with provocative maneuvers.

Electrodiagnostic testing can support the diagnosis and determine severity but is not mandatory in every straightforward case.

Signs and Symptoms

Typical symptoms include numbness and tingling in the median nerve distribution, hand weakness or clumsiness, and pain involving the hand, wrist, or distal forearm.

Symptoms are frequently worse at night.

Many patients wake from sleep because of painful numbness or tingling and may shake the hand to obtain relief.

Sensory Distribution

Paresthesias typically involve the thumb, index finger, middle finger, and radial half of the ring finger.

The little finger is usually spared.

Symptoms may occasionally radiate proximally into the wrist or forearm.

Motor Symptoms

Patients may notice difficulty with tasks requiring fine motor control, such as buttoning clothing, handling coins, writing, or gripping small objects.

More advanced disease may cause weakness of thumb palmar abduction due to involvement of the abductor pollicis brevis.

Nocturnal Symptoms

Nighttime symptoms are particularly characteristic.

Wrist flexion during sleep may increase carpal tunnel pressure and aggravate median nerve compression.

This explains why neutral-position nighttime splinting can be effective.

Tinel Sign

The Tinel sign is elicited by gently tapping over the median nerve at the carpal tunnel while the wrist is held in a neutral position.

A positive test reproduces tingling or electric sensations in the median nerve distribution of the hand.

Phalen Test

The Phalen test is performed by placing the wrist in full flexion, traditionally around 90°, and maintaining the position.

Development of paresthesias in the median nerve distribution within approximately 30–60 seconds supports the diagnosis.

Flexion-Compression Test

For the flexion-compression test, the elbow is extended and the forearm is supinated.

The wrist is flexed to approximately 60°, and direct pressure is applied over the median nerve at the carpal tunnel.

Reproduction of median-distribution paresthesias within about 30 seconds is considered a positive finding.

Physical Examination

The hand should be inspected for thenar muscle wasting.

Strength of thumb palmar abduction should be assessed carefully because weakness may indicate advanced median nerve compression.

Thenar Atrophy

Visible flattening or wasting of the thenar eminence suggests chronic or severe CTS.

Once substantial muscle atrophy has developed, full motor recovery after decompression may be incomplete.

Sensory Examination

Sensation should be tested over the thumb and fingers.

Two-point discrimination can be measured on the radial and ulnar sides of each fingertip.

Normal discrimination is generally less than approximately 5–6 mm, or should be symmetric with the opposite hand when symptoms are unilateral.

Examination for Other Neuropathies

The entire upper extremity should be examined for alternative or additional sites of nerve compression.

Conditions such as cervical radiculopathy, proximal median nerve entrapment, and cubital tunnel syndrome may mimic or coexist with CTS.

Laboratory Tests

Laboratory investigations are not required in every patient but may be useful when a systemic cause is suspected.

Tests may include erythrocyte sedimentation rate, serum glucose, serum uric acid, and thyroid function studies.

These investigations may identify inflammatory, metabolic, endocrine, or crystal-related conditions contributing to nerve compression.

Electrodiagnostic Studies

Electromyography and nerve conduction studies can confirm median nerve compression at the wrist and help determine its severity.

They can also identify additional abnormalities elsewhere along the nerve pathway.

Double-Crush Syndrome

Electrodiagnostic testing may help detect a double-crush syndrome, in which median nerve dysfunction at the wrist coexists with a more proximal lesion, such as cervical radiculopathy or proximal median nerve compression.

This possibility is particularly important when symptoms persist despite apparently adequate carpal tunnel treatment.

Imaging

Plain Radiographs

Routine radiographs are not necessary for uncomplicated CTS.

Wrist radiographs may be useful in patients with a history of trauma, deformity, or longstanding inflammatory arthritis.

They can demonstrate fractures, malalignment, arthritis, or other structural abnormalities affecting the carpal tunnel.

Cervical Spine Imaging

Cervical spine radiographs may be useful when a proximal neurologic cause is suspected.

They can also demonstrate abnormalities such as a cervical rib when thoracic outlet syndrome is being considered, although thoracic outlet symptoms more often resemble ulnar-sided neuropathy.

Differential Diagnosis

Important differential diagnoses include thoracic outlet syndrome, cervical nerve root compression from degenerative disc disease or tumor, proximal median nerve entrapment, and cubital tunnel syndrome.

Clinical distribution of symptoms and electrodiagnostic testing can help distinguish these disorders.

Treatment

General Measures

Initial management is usually nonoperative, particularly in mild or intermittent disease.

The principal conservative measures are nighttime wrist splinting, activity modification, and corticosteroid injection in selected patients.

Nighttime Splinting

A wrist splint should hold the wrist in a neutral position during sleep.

Excessive flexion or extension increases carpal tunnel pressure and can worsen symptoms.

Night splinting is particularly useful for patients with nocturnal paresthesias.

Duration of Splinting

To determine whether conservative treatment is effective, nighttime splinting should generally be used consistently for at least 1 month.

Patients who improve while wearing the splint but experience rapid symptom recurrence after discontinuation may ultimately require surgical treatment.

Activity Modification

When symptoms are associated with work or repetitive activity, modification of the provoking tasks is recommended.

Reducing forceful gripping, repetitive wrist motion, prolonged wrist flexion or extension, and other aggravating activities may reduce symptoms.

Corticosteroid Injection

A corticosteroid injection into the carpal tunnel may provide temporary or sometimes prolonged symptom relief.

Injection should be performed by an experienced clinician because inadvertent injection into or injury of the median nerve can cause significant neurologic damage.

Indications for Corticosteroid Injection

Injection is particularly useful when compression is expected to be temporary, such as during pregnancy, or when modification of the precipitating activity is feasible.

It may also serve as a therapeutic trial in mild to moderate CTS.

Physical Therapy

Formal physical therapy is not routinely required for uncomplicated carpal tunnel syndrome.

Therapy may be useful for workplace modification, ergonomic assessment, or selected hand and nerve-gliding programs, although these are generally adjunctive rather than primary treatment.

Medication

No oral medication has been shown to specifically reverse median nerve compression within the carpal tunnel.

Analgesics may relieve pain temporarily but do not correct the underlying mechanical compression.

Indications for Surgery

Carpal tunnel release is considered when conservative treatment has failed or when there is evidence of constant numbness, motor weakness, thenar atrophy, or significant electrodiagnostic abnormality.

Progressive neurologic deficit is a particularly strong indication for decompression.

Surgical Principle

The goal of surgery is to decompress the median nerve by dividing the transverse carpal ligament.

This increases the volume of the carpal tunnel and reduces pressure on the nerve.

Open Carpal Tunnel Release

Open release is performed through a longitudinal palmar incision.

The incision is typically positioned in line with the ulnar border of the ring finger axis and provides direct visualization of the transverse carpal ligament and median nerve.

The ligament is divided completely to decompress the nerve.

Mini-Open Release

A mini-open technique uses a smaller incision while maintaining direct visualization of the ligament.

Its aim is to reduce soft-tissue disruption while achieving complete decompression.

Endoscopic Carpal Tunnel Release

Endoscopic release divides the transverse carpal ligament through one or more small portals using an endoscopic system.

Long-term results are generally similar to those of open release.

Some patients may return to work more quickly and experience less early scar discomfort.

Open Versus Endoscopic Release

At approximately 6 months and beyond, open and endoscopic procedures generally provide comparable symptom relief.

Endoscopic release may result in faster early functional recovery and less scar tenderness in some patients.

However, the risk of nerve injury may be slightly higher with endoscopic techniques.

Follow-Up

Patients treated conservatively should be reassessed for persistence or progression of numbness, nocturnal symptoms, weakness, and functional impairment.

Failure of a reasonable period of nonoperative management may warrant surgical referral.

Prognosis With Nonoperative Treatment

Many patients with mild or occupationally related CTS improve with a combination of night splinting, corticosteroid injection, and modification of aggravating activities.

If the provoking work activity continues unchanged, conservative measures may provide only temporary relief.

Prognosis After Surgery

Pain often improves very quickly after carpal tunnel release.

Numbness usually recovers more gradually over the following weeks to months because the median nerve requires time to recover from chronic compression.

Severe Compression

Patients with longstanding or severe compression may not regain completely normal sensation or motor strength even after technically successful decompression.

Permanent nerve injury may already have occurred before surgery.

Recovery of Strength

Grip and thenar strength may take 6 months or longer to recover maximally after release.

The speed and completeness of recovery depend partly on the duration and severity of preoperative nerve compression.

Complications

Possible complications include iatrogenic injury to the median nerve or its branches, painful scar formation, pillar pain, incomplete release, infection, and persistent or recurrent symptoms.

Nerve injury can occur with either open or endoscopic surgery but may be slightly more frequent with endoscopic techniques.

Scar Sensitivity

Tenderness or hypersensitivity around the surgical incision can occur, particularly after open release.

This usually improves gradually over several months but may persist in a minority of patients.

Pillar Pain

Pillar pain refers to discomfort on either side of the carpal tunnel after release, often around the thenar or hypothenar regions.

It commonly improves with time but can temporarily interfere with gripping or weight-bearing through the palm.

Persistent Symptoms After Surgery

Persistent symptoms after decompression may result from incomplete division of the transverse carpal ligament, an incorrect initial diagnosis, severe irreversible nerve damage, or an untreated proximal compression site.

A double-crush syndrome or generalized peripheral neuropathy should also be considered.

Patient Monitoring

Patients receiving conservative treatment should be monitored for progression from intermittent symptoms to constant numbness or motor weakness.

Development of thenar atrophy or persistent sensory loss should prompt surgical consideration.

Postoperative Monitoring

After surgery, patients are typically reviewed for wound assessment and suture removal.

Activity can then be increased progressively if wound healing is satisfactory.

Neurologic recovery may continue for several months after the incision itself has healed.

Patient Teaching

Patients should avoid prolonged or repetitive wrist positions that aggravate symptoms.

Workstation or occupational modifications may be useful when symptoms are related to repetitive or forceful hand activity.

Prevention

Reducing prolonged wrist flexion or extension and minimizing repetitive forceful hand use may help decrease symptoms in susceptible individuals.

Maintaining appropriate ergonomic wrist positioning may also be beneficial.

Frequently Asked Question: Should Pregnancy-Related CTS Be Treated Surgically?

CTS arising during pregnancy often improves after delivery.

Initial treatment should therefore consist of nighttime neutral wrist splinting, with corticosteroid injection considered when appropriate.

Surgery is generally deferred until after delivery so that spontaneous resolution can be assessed, although severe cases can be treated surgically under local anesthesia when necessary.

Frequently Asked Question: Can CTS Recur After Surgical Release?

True recurrence after an adequately performed release is uncommon.

Persistent or recurrent symptoms should prompt evaluation for incomplete ligament release, an alternative diagnosis, double-crush syndrome, or an underlying peripheral neuropathy.

Frequently Asked Question: What Are the Typical Symptoms?

Typical symptoms are pain, numbness, and tingling, especially at night.

The sensory symptoms usually involve the thumb, index finger, middle finger, and radial half of the ring finger.

Patients may also experience difficulty with fine motor tasks or hand clumsiness.

When motor weakness develops, the abductor pollicis brevis is commonly affected.

Orthopaedic Surgery - Camptodactyly

Basics

Camptodactyly is a nontraumatic flexion deformity of the proximal interphalangeal (PIP) joint that may gradually progress over time.

It most commonly involves the little finger, although one or more adjacent fingers may occasionally be affected.

The condition may occur in isolation or as part of a recognized congenital or genetic syndrome.

Types of Camptodactyly

Two main clinical patterns are recognized: early-onset and delayed-onset camptodactyly.

The early form develops during the first year of life and is the more common type.

It affects males and females approximately equally.

The delayed or late form usually begins after approximately 10 years of age and occurs predominantly in girls.

Terminology

The two patterns have sometimes been described as congenital and adolescent camptodactyly.

However, some clinicians prefer the terms early and delayed or late camptodactyly because both forms probably represent variations of the same underlying disorder rather than completely separate diseases.

Importance of Age at Treatment

Treatment generally produces the best results when initiated during childhood or adolescence.

Once the deformity becomes longstanding and fixed in adulthood, correction is much more difficult and the results of treatment are generally poor.

Epidemiology

Camptodactyly is uncommon and affects less than 1% of the population.

Risk Factors

A positive family history increases the likelihood of developing the condition.

However, many affected patients have no known relatives with camptodactyly.

Genetics

Many cases occur sporadically.

Familial cases may demonstrate autosomal dominant inheritance, although expression and severity can vary considerably among family members.

Pathophysiology

The precise structural abnormality responsible for camptodactyly is variable.

Almost every soft-tissue structure capable of producing PIP flexion has been implicated.

The final deformity results from an imbalance between the flexor and extensor mechanisms of the PIP joint.

Lumbrical Abnormalities

Abnormalities of the lumbrical muscle may include absence, atrophy, or an abnormal insertion into the lumbrical canal.

These abnormalities can alter the balance of forces across the PIP joint and contribute to progressive flexion.

Flexor Tendon Abnormalities

A fibrous band may arise from the A1 pulley and insert into the flexor digitorum superficialis tendon.

The flexor digitorum superficialis may also have an abnormal origin from the palmar fascia.

Other abnormalities include anomalous tendons and a relatively short flexor digitorum profundus.

Capsular and Ligamentous Abnormalities

Contracture of the collateral ligaments or volar plate may develop as the deformity progresses.

These secondary changes make the PIP joint increasingly stiff and can convert an initially flexible deformity into a fixed contracture.

Etiology

Camptodactyly is thought to result from disturbed balance between the flexor and extensor mechanisms at the PIP joint.

Frequently identified anatomical abnormalities include unusual insertions or relationships of the lumbrical muscle, flexor digitorum superficialis, and retinacular ligamentous structures.

Because the anatomic cause differs among patients, no single treatment is successful in every case.

Associated Conditions

Camptodactyly may occur as part of several syndromes and congenital disorders.

Reported associations include trisomy 13–15, oculodentodigital syndrome, orofaciodigital syndrome, Aarskog syndrome, cerebrohepatorenal syndrome, mucopolysaccharidosis, osteo-onychodysostosis, and Jacob-Downey syndrome.

Diagnosis

Signs and Symptoms

The characteristic finding is a flexion deformity of the PIP joint, most commonly affecting the little finger.

Adjacent fingers may occasionally demonstrate similar involvement.

Pain and swelling are usually absent, even when the contracture is severe.

Bilateral Involvement

Approximately two-thirds of patients have involvement of both hands.

The degree of deformity does not necessarily match from side to side.

When only one hand is affected, the right hand is more commonly involved.

Position of the MCP Joint

The metacarpophalangeal joint is often held in slight hyperextension.

This compensatory posture may partially offset the functional effect of PIP flexion.

For this reason, relatively mild contractures can be well tolerated.

Effect of Wrist Position

In children, the deformity may become less pronounced or temporarily disappear when the wrist is flexed.

This finding reflects the dynamic relationship between the flexor tendons and PIP joint position.

Severe Deformity

In more advanced cases, the finger may also develop a rotational component.

The patient may complain that the digit interferes with gripping, typing, tapping, or other fine hand activities.

Camptodactyly Versus Clinodactyly

Camptodactyly should not be confused with clinodactyly.

Camptodactyly describes a flexion deformity in the sagittal plane at the PIP joint.

Clinodactyly refers to angular deviation of a digit in the radioulnar plane.

Physical Examination

Active and passive motion of the PIP and MCP joints should be carefully measured.

The examination should be performed with the wrist in both flexion and extension.

This helps determine how much of the deformity is dynamic and how much represents a fixed contracture.

Flexible Versus Fixed Deformity

An important part of the examination is determining whether the PIP contracture can be corrected passively.

A flexible deformity is more likely to respond to splinting and stretching.

A fixed contracture suggests established soft-tissue or joint changes and has a less favorable prognosis.

Imaging

Plain Radiographs

Plain radiographs of the involved digit should be obtained, particularly when the deformity is longstanding or severe.

Early in the condition, radiographs may be relatively normal.

Structural changes can develop with growth and prolonged contracture.

Radiographic Changes

Longstanding camptodactyly may produce broadening of the base of the middle phalanx.

The neck of the proximal phalanx may become indented, giving the proximal phalangeal head a characteristic beaked appearance.

Advanced Joint Changes

Other radiographic abnormalities may include narrowing of the PIP joint space, dorsal flattening of the proximal phalangeal condyle, flattening of the palmar surface, and volar subluxation of the middle phalanx.

These structural changes indicate a more established deformity and reduce the likelihood of achieving complete correction.

Differential Diagnosis

Diagnosis is based primarily on a careful history and physical examination.

The differential diagnosis includes clinodactyly, post-traumatic deformity, Dupuytren contracture, arthrogryposis, absence or hypoplasia of an extensor tendon, Marfan syndrome, Beals syndrome or congenital contractural arachnodactyly, pterygium syndrome, symphalangism, and boutonniere deformity.

Treatment

General Principles

There is no single universally successful treatment because camptodactyly can arise from several different anatomical abnormalities.

The goal is to restore or improve the balance between the flexor and extensor mechanisms while maintaining useful joint motion.

Early-Onset Camptodactyly

In early-onset disease, the preferred initial treatment is generally progressive extension splinting.

Because younger patients often have flexible soft tissues and less-established joint deformity, conservative treatment can be particularly effective.

Delayed-Onset Camptodactyly

Delayed or adolescent camptodactyly is also initially treated conservatively.

Surgery may be considered if the deformity is severe, progressive, functionally limiting, or fails to respond to splinting.

Mild Contractures

A PIP flexion contracture of less than approximately 30–40° often causes little functional impairment.

Compensatory hyperextension at the MCP joint allows many patients to use the hand normally.

In such cases, observation and acceptance of the deformity are often preferable to surgery.

Counseling

Patients and families should be informed that operative results can be unpredictable.

For mild deformities, many surgeons recommend accepting the appearance rather than risking increased stiffness or pain from surgery.

Splinting

Splinting is the mainstay of conservative treatment.

Static extension splints, often worn at night, can help maintain or improve PIP extension.

Progressive splinting is especially effective when the deformity remains flexible.

Serial Casting

Serial plaster casting may be used when splinting alone does not provide sufficient correction.

The PIP joint is gradually brought toward extension over a series of casts.

Casting should generally be attempted before operative treatment.

Occupational Therapy

Occupational or hand therapy may be helpful in both early and delayed forms.

The therapist can supervise stretching, splint fabrication, skin care, and progressive range-of-motion exercises.

Night splinting is often recommended to reduce progression.

Indications for Surgery

Surgery is generally reserved for severe and progressive deformity, especially when the flexion contracture exceeds approximately 60° and causes functional limitation or significant unacceptable deformity.

Operative intervention may also be considered to prevent progressive, irreversible articular changes in carefully selected patients.

Patient Selection for Surgery

Surgical candidates should be chosen carefully.

The best candidates are younger patients with deformities that remain at least partially correctable and have a clearly defined anatomical cause.

A treatment plan should be tailored to the clinical examination rather than applying a single operation to every patient.

Surgical Goals

Surgery attempts to correct the abnormal anatomy by releasing, lengthening, or transferring abnormal muscle, tendon, capsular, or ligamentous structures.

Because multiple abnormalities may coexist, procedures are often performed in a stepwise fashion.

Soft-Tissue Release

Severe deformities may require release of contracted skin and soft tissues.

Local flap coverage may occasionally be needed when correction creates a skin deficit.

Flexor Digitorum Superficialis Tenotomy

When the flexor digitorum superficialis contributes significantly to the contracture, tenotomy or lengthening may be performed.

This reduces the abnormal flexion force across the PIP joint.

Volar Plate Release

A contracted volar plate can prevent full PIP extension.

A sliding or formal volar plate release may be incorporated into surgical correction when capsular contracture is present.

Extensor Mechanism Rebalancing

Residual extension lag may require procedures aimed at restoring the balance of the extensor mechanism.

These procedures can include tendon transfers or adjustments of the central slip and lateral bands.

Fowler Tenotomy

In selected severe cases, a Fowler-type tenotomy may be used as part of extensor mechanism rebalancing.

The procedure alters the relationship between the central slip and lateral bands to improve extension forces across the PIP joint.

Tendon Transfer

Tendon transfer may be considered particularly in adolescent camptodactyly when an abnormal tendon or muscular imbalance is a major contributor.

The goal is to redirect force and improve active PIP extension.

Corrective Osteotomy

If radiographs demonstrate established bony deformity or joint remodeling, a procedure aimed solely at increasing joint motion may be ineffective.

In these cases, a corrective extension osteotomy may provide better alignment.

PIP Arthrodesis

When the PIP joint is severely damaged, deformed, painful, or no longer salvageable, PIP joint arthrodesis may be considered.

Fusion sacrifices motion but can provide a stable finger positioned in a more functional alignment.

Surgery in Adults

Corrective surgery initiated in adulthood generally produces poor results.

Adult patients are at greater risk of increased stiffness and pain after intervention.

For this reason, routine reconstructive surgery in adults is generally discouraged unless there is a compelling functional indication.

Follow-Up

Camptodactyly should be monitored throughout growth because progression is common during childhood and adolescence.

The degree of PIP contracture, passive correctability, hand function, and radiographic changes should be followed over time.

Prognosis

Without treatment, approximately 80% of cases may progressively worsen.

Progression is particularly common during periods of rapid skeletal growth.

Growth Spurts

The deformity often becomes more noticeable during growth spurts, when abnormal soft-tissue structures fail to lengthen at the same rate as the skeleton.

This is why periodic reassessment during childhood and adolescence is important.

Natural History After Maturity

Progression usually slows or stops after approximately 18–20 years of age, once skeletal growth is complete.

However, any fixed contracture present at maturity may persist permanently.

Complications

Surgery, particularly in adults or patients with longstanding fixed deformity, can lead to increased PIP stiffness and pain.

Other potential problems include incomplete correction, recurrence, scarring, or reduced active motion.

Patient Monitoring

Because younger patients have the greatest potential for successful treatment, early recognition and continued monitoring are important.

The deformity should be reassessed during periods of growth for increasing contracture or functional limitation.

Patient Teaching

Patients and families should inspect the skin regularly when splints are being used.

Pressure areas, redness, or skin breakdown should prompt adjustment of the splint.

Stretching should continue after completion of casting or intensive splinting to preserve the correction achieved.

Activity

Most patients require no activity restrictions.

Mild deformity usually does not interfere significantly with daily life, sports, or school activities.

Severe contracture may interfere with occupations, sports, or tasks requiring precise fine-motor hand function.

Prevention

There is no established method for preventing camptodactyly.

Early identification and treatment may, however, reduce progression and secondary joint deformity.

Frequently Asked Question: How Often Are Both Hands Involved?

Camptodactyly is bilateral in approximately two-thirds of patients.

The little finger is the most commonly affected digit, although adjacent fingers may also be involved.

Frequently Asked Question: Is Surgery Usually Recommended?

No. Mild contractures of less than approximately 30–40° generally cause little functional impairment and are usually treated nonoperatively.

Because surgical results are variable, surgery is generally reserved for severe, progressive deformities that interfere with function or produce major unacceptable deformity.

Stretching should be continued after the splinting or casting program to maintain the gain achieved  Activity Generally, no limitations are placed on activity

In severe cases, the deformity may pose a problem in sports or occupations requiring fine work with the hands  Prevention No effective means of prevention exists  FAQ Q: How often does camptodactyly affect both hands?

A: It is bilateral in 2/3 of cases; the 5th finger is most commonly involved. Q: Is surgery recommended to correct the deformity?  A: Mild contracture (<30–40°) does not interfere with function and should be treated nonoperatively. Surgical results are not consistent, and surgery usually is reserved for more severe cases that hinder activity.

Orthopaedic Surgery - Calcaneovalgus Foot

Basics

Calcaneovalgus foot is a congenital positional deformity believed to result from abnormal positioning of the fetal foot within the uterus.

The hindfoot is held in valgus, while the entire foot is markedly dorsiflexed.

In pronounced cases, the dorsum of the foot may rest against or nearly touch the anterior surface of the tibia.

Epidemiology

Calcaneovalgus foot is seen in newborn infants.

It occurs more frequently in girls and has an association with breech presentation or delivery.

It is one of the most common congenital foot deformities encountered in the neonatal period.

Prevalence

The condition has been reported in varying degrees in approximately 0.5–30% of births.

The wide range reflects differences in diagnostic criteria and the fact that mild positional deformities may resolve rapidly.

Pathophysiology

Calcaneovalgus foot is primarily a soft-tissue positional deformity rather than a structural bony abnormality.

The Achilles tendon is temporarily stretched because the foot has been held in excessive dorsiflexion.

After birth, the soft tissues gradually regain normal length and balance, and spontaneous correction usually occurs.

Bony Anatomy

There are no primary bony abnormalities in a typical calcaneovalgus foot.

This distinction is important because structural congenital deformities such as vertical talus require different treatment.

Associated Conditions

Infants with calcaneovalgus feet should be examined for other positional abnormalities that may also result from intrauterine positioning.

Important associated conditions include developmental dysplasia of the hip (DDH) and torticollis.

Relationship to Pes Planus

There is no convincing evidence that calcaneovalgus foot predisposes a child to pes planus or flatfoot later in life.

Most affected feet develop normal shape and function.

Diagnosis

Signs and Symptoms

The deformity is present at birth and is generally painless and asymptomatic.

The foot is markedly dorsiflexed, often to the point that its dorsum rests against the anterior tibia.

The hindfoot is positioned in valgus.

Muscle Tightness

Occasionally, there may be temporary contracture or tightness of the anterior compartment muscles and dorsiflexors.

Despite this, the deformity is usually flexible.

Flexibility of the Foot

Most calcaneovalgus feet can be passively brought into plantarflexion without substantial difficulty.

The degree of flexibility is an important diagnostic feature and helps distinguish the condition from fixed structural deformities.

Physical Examination

The appearance of the foot is usually sufficient to establish the diagnosis.

The examiner should assess whether the foot can be passively plantarflexed and supinated.

In some newborns, complete correction may not be achievable immediately, but progressive improvement should occur.

Calcaneal Position

The orientation of the calcaneus is especially important.

In calcaneovalgus foot, the hindfoot is dorsiflexed, and the heel points downward.

This finding helps distinguish the condition from congenital vertical talus.

Imaging

Plain Radiographs

Imaging is not routinely required when the physical examination is typical.

If the diagnosis is uncertain, standard anteroposterior and lateral radiographs of the foot and ankle may be obtained.

Radiographs are primarily used to exclude a structural or bony abnormality.

Differential Diagnosis

The main differential diagnoses include congenital vertical talus, posteromedial bowing of the tibia, and neurologic dorsiflexion deformity caused by L5 weakness.

Careful examination of the hindfoot and tibia usually differentiates these conditions.

Congenital Vertical Talus

Congenital vertical talus, also called convex pes valgus, is a rigid structural foot deformity.

Unlike calcaneovalgus foot, the calcaneus is held in plantarflexion or equinus.

The Achilles tendon is contracted, and the navicular is dorsally dislocated over the talar neck.

Distinguishing Vertical Talus

The direction of the heel is a useful clinical clue.

In congenital vertical talus, the heel is positioned upward because the calcaneus is plantarflexed.

In calcaneovalgus foot, the heel points downward because the calcaneus is dorsiflexed.

Posteromedial Bowing of the Tibia

Posteromedial bowing of the tibia can produce a foot that appears dorsiflexed and everted, similar to calcaneovalgus.

However, the primary abnormality is a bow in the tibia itself, rather than a positional deformity at the foot and ankle.

The bony curvature can usually be palpated on examination.

L5 Paresis

Neurologic weakness involving the L5 nerve root, such as may occur in spina bifida, can produce a fixed dorsiflexed foot because of muscle imbalance.

The presence of neurologic abnormalities and a less flexible deformity helps distinguish this from simple calcaneovalgus.

Treatment

General Measures

The most important aspect of treatment is reassurance of the parents.

Calcaneovalgus foot is a benign positional deformity that usually corrects spontaneously as the infant grows.

Parents may require repeated reassurance because the initial appearance can be dramatic.

Stretching

Gentle stretching exercises may be performed several times each day.

Parents can be taught to gently plantarflex and supinate the foot to encourage correction.

These exercises are optional in mild cases because spontaneous improvement is expected even without treatment.

Serial Casting

Occasionally, when the deformity is more pronounced or correction is slower than expected, serial casting may be used.

Casting can accelerate correction by maintaining the foot in a more neutral position.

Activity

No activity restrictions are necessary.

The deformity usually improves rapidly and does not interfere with normal infant development.

Surgery

Surgical treatment is not required for true calcaneovalgus foot.

The need for surgery should prompt reconsideration of the diagnosis and evaluation for another structural deformity.

Referral

Infants with a marked deformity, an unusually rigid foot, or possible congenital vertical talus should be referred to an orthopaedic specialist.

Referral is also appropriate when the diagnosis is uncertain or expected spontaneous improvement does not occur.

Follow-Up

Most infants require only periodic clinical observation.

Follow-up should document progressive improvement in foot position and confirm that the hindfoot becomes increasingly flexible and normally aligned.

Prognosis

The prognosis is excellent.

The deformity gradually corrects, and affected children generally develop a foot with normal appearance, strength, alignment, and function.

Long-Term Outcome

There is no definite evidence that children with calcaneovalgus foot are more likely to develop flatfoot later in life.

Normal walking and activity are expected.

Complications

Complications are rare.

Occasionally, subluxation of the peroneal tendons may occur.

When present, this problem generally responds to serial casting and resolves without long-term functional impairment.

Patient Monitoring

Parents should observe for progressive spontaneous correction.

Persistent rigidity, failure to improve, worsening deformity, or an abnormal heel position should prompt reassessment to exclude congenital vertical talus or another structural or neurologic disorder.

Orthopaedic Surgery - Burners (Stingers)

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Basics

A burner or stinger is a transient neurologic injury most commonly seen in athletes participating in contact or collision sports.

The injury usually involves compression, traction, or a combination of both affecting the upper trunk of the brachial plexus, particularly the C5 and C6 nerve roots.

Patients typically experience a sudden burning or electric pain radiating from the neck or shoulder into the arm, sometimes accompanied by numbness, tingling, or weakness.

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Mechanism of Compression

Compression can occur when the athlete’s head is forcibly turned or bent toward the injured side.

This narrows the neural foramina and may compress the cervical nerve roots or upper brachial plexus.

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Mechanism of Traction

Traction injury occurs when the shoulder and arm are forced downward while the neck bends or rotates toward the opposite side.

This stretches the upper portion of the brachial plexus and may transiently impair nerve conduction.

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Direct-Blow Mechanism

A direct impact over Erb point, located approximately 2–3 cm above the clavicle where the C5 and C6 nerve roots converge, can also produce a stinger.

This mechanism can directly compress or contuse the upper trunk of the brachial plexus.

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Age-Related Pattern

Burners are more commonly encountered in younger athletes.

Older athletes experiencing a similar mechanism are more likely to have a cervical nerve root injury because degenerative changes and cervical stenosis become more common with age.

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Classification

Stingers can be classified according to the severity of nerve injury.

Grade I represents a neurapraxia, in which nerve conduction is temporarily impaired without permanent structural disruption. Symptoms are generally short-lived and there may be no persistent motor or sensory deficit.

Grade II represents axonotmesis, with disruption of axons but preservation of some supporting nerve structures. Motor weakness is usually present and sensory symptoms may also occur.

Grade III represents neurotmesis, the most severe form, with major disruption of the nerve. Motor or sensory deficits may persist for longer than a year.

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General Prevention

The only complete method of prevention is avoidance of activities involving significant contact or collision.

For athletes who continue participating, prevention should focus on appropriate equipment, correct technique, and conditioning.

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Protective Equipment

In American football, neck collars or similar protective devices may reduce excessive cervical motion and may help decrease the likelihood of recurrent stingers in selected athletes.

Helmets and shoulder pads should be checked to ensure proper fit.

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Sports Technique

Proper tackling and blocking technique is important.

Athletes should avoid leading with the head or placing the cervical spine in positions that produce excessive lateral bending or extension.

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Strengthening

Strengthening the neck, shoulder girdle, and scapular stabilizing muscles may reduce recurrence.

Improved muscular control can help limit excessive neck and shoulder displacement during contact.

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Epidemiology

Burners occur predominantly in young male athletes involved in contact sports, particularly American football and rugby.

Recurrence is common.

Recent studies suggest that approximately one-fifth to one-third of stinger episodes may represent recurrent injuries.

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Incidence

In collegiate American football, an incidence of approximately 2.04 injuries per 10,000 athlete exposures has been reported.

In one rugby cohort, approximately 21% of players experienced a stinger, with a reinjury rate of approximately 37% during the same season.

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Risk Factors

A previous history of a stinger is the strongest predictor of a future episode.

Cervical spinal or foraminal stenosis is another important risk factor because it reduces the space available for the cervical nerve roots.

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Genetics

No specific genetic association has been identified.

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Etiology

Most burners result from compression, traction, or combined compression and traction of the upper brachial plexus.

In American football, the majority occur during tackling or blocking.

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Associated Conditions

Recent evidence suggests an association between recurrent stingers and scapular dyskinesis, particularly in rugby athletes.

Abnormal scapular mechanics may alter shoulder and cervical positioning during contact and increase neural stress.

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Diagnosis

Signs and Symptoms

The classic symptom is an immediate sharp, burning, or electric pain radiating from the shoulder or neck down one arm.

Paresthesias, numbness, or weakness may accompany the pain.

Symptoms usually resolve within several minutes, although some athletes experience weakness or sensory disturbance lasting much longer.

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Delayed Weakness

Strength may initially appear normal immediately after injury.

However, weakness can occasionally develop or become more noticeable over the following hours or days.

For this reason, serial neurologic examination is important.

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Physical Examination

The examination should begin with assessment of the cervical spine and affected upper extremity.

If the athlete has no neck pain or tenderness, cervical range of motion may be evaluated carefully.

A simple stinger usually allows full and painless cervical motion.

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Palpation

There is often no significant tenderness over the cervical spine, clavicle, or shoulder.

Tenderness over these areas should raise suspicion for an associated fracture, dislocation, or structural injury.

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Neurologic Examination

Motor strength and sensation should be compared with the contralateral side.

Transient weakness most commonly follows a C5–C6 distribution.

Affected muscles may include the deltoid, biceps, and shoulder external rotators.

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Spurling Test

The Spurling test may reproduce symptoms when cervical nerve root compression contributes to the injury.

The neck is placed into extension, rotation, and lateral bending toward the symptomatic side, followed by gentle axial compression.

Reproduction of radiating symptoms into the ipsilateral arm is considered a positive test.

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Bilateral Symptoms

Bilateral arm symptoms are not typical of a simple stinger and should raise concern for a cervical spinal cord or major cervical spine injury.

If both arms are involved, the athlete should be treated as having a potentially unstable cervical spine injury.

The neck should be immobilized, and protective equipment should generally remain in place until appropriate transport and evaluation can be completed.

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Imaging

Indications for Cervical Radiographs

Routine imaging is not necessary after every uncomplicated first-time stinger that resolves rapidly.

Cervical radiographs should be considered when the patient has recurrent episodes, neck pain, stiffness, tenderness, or pain with cervical range of motion.

Radiographs can help identify fracture, alignment abnormalities, or cervical stenosis.

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MRI

MRI of the cervical spine is particularly important when symptoms are bilateral, persistent, recurrent, or associated with abnormal neurologic findings.

It can evaluate for cervical stenosis, disc herniation, nerve root compression, or spinal cord pathology.

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Pathological Testing

Histologic or other pathological testing is not routinely required for the diagnosis.

Burners are diagnosed primarily through clinical history, physical examination, and selective imaging or electrodiagnostic testing.

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Differential Diagnosis

Important differential diagnoses include cervical spine fracture, cervical disc herniation, clavicle fracture, shoulder fracture or dislocation, and soft-tissue injuries of the shoulder.

Because these conditions can mimic or accompany a stinger, careful examination is essential before return to play.

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Treatment

Initial Management

The athlete should be removed immediately from play after a stinger.

Return should not be permitted while pain, paresthesias, weakness, sensory loss, or restricted motion remains.

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Return-to-Play Criteria

Accepted criteria for return include full and painless cervical and shoulder range of motion, complete resolution of paresthesias, normal sensation, and full strength.

The athlete should also be able to participate in practice without recurrent symptoms before returning to unrestricted competition.

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Same-Day Return to Play

A player may return during the same event only when symptoms have completely resolved and the examination is normal.

There should be no pain at rest or during provocative testing, and strength and sensation must be equivalent to the opposite side.

Any residual neurologic abnormality is a contraindication to immediate return.

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Persistent Neurologic Deficit

Athletes with incomplete neurologic recovery should undergo repeated examinations.

They should not return to contact sport until strength, sensation, and range of motion have fully normalized.

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Recurrent Stingers

Athletes with repeated episodes should not return to play until an appropriate cervical spine evaluation has been completed.

Imaging should exclude structural conditions such as stenosis or disc herniation that could increase the risk of further neurologic injury.

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Cervical Foraminal Stenosis

Athletes with significant cervical foraminal or spinal canal stenosis require particularly careful counseling.

When clinically significant stenosis is present, avoidance of contact and collision sports may be recommended because of the risk of recurrent or more serious neurologic injury.

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Electromyography and Return to Sport

An abnormal electromyographic study does not automatically prohibit return to sport.

Return-to-play decisions should be individualized according to symptoms, strength, neurologic examination, imaging, and the pattern of electrodiagnostic abnormalities.

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Physical Therapy

Physical therapy can improve neck and shoulder range of motion, flexibility, strength, and neuromuscular control.

Rehabilitation commonly emphasizes cervical strengthening, shoulder girdle conditioning, posture, and scapular stabilization.

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First-Line Management

The athlete should remain out of competition until all symptoms have resolved.

Serial neurologic examinations should document recovery of motor function, sensation, reflexes, and cervical motion.

Athletes with recurring symptoms should undergo imaging before returning to play.

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Electromyography

Electromyography is generally considered when weakness, numbness, or other neurologic symptoms persist beyond approximately 3 weeks.

It can help determine the severity and location of nerve injury and identify evidence of axonal loss.

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Further Imaging After EMG

MRI should be considered when electromyography is abnormal or when symptoms involve both upper extremities.

MRI can identify cervical spinal stenosis, disc disease, or another structural cause of persistent neurologic dysfunction.

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Follow-Up

Patients should undergo repeat examination until symptoms have resolved completely.

Strength, sensation, and range of motion should be compared with the opposite side during follow-up.

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Prognosis

The prognosis after an isolated stinger is generally excellent.

Most athletes recover rapidly, and many miss little or no playing time.

In one rugby cohort, the average return to play was approximately 2.9 days, with the majority of athletes missing no competition.

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Duration of Symptoms

The mean symptom duration in one study was approximately 3.5 days, although most episodes resolved within 24 hours.

Longer-lasting symptoms are more concerning for a higher-grade nerve injury.

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Prognostic Factors

A history of repeated stingers with multiple associated symptoms, particularly motor weakness, is associated with greater injury severity.

Frequent recurrence should prompt investigation for underlying cervical stenosis or other structural abnormalities.

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Recurrence

Recurrence is one of the major clinical problems associated with stingers.

Some older studies reported recurrence rates as high as 87%, although rates vary considerably depending on sport, study population, and diagnostic criteria.

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Complications

The overall risk of permanent nerve damage after a simple isolated stinger is low.

However, recurrent episodes may occasionally lead to chronic neurologic symptoms or persistent weakness.

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Chronic Stinger Syndrome

A minority of athletes with frequent recurrent stingers can develop a more persistent syndrome.

Cervical stenosis has a strong association with chronic or recurrent symptoms in these patients.

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Patient Monitoring

A detailed neurologic examination should be performed at the time of injury and compared with the unaffected side.

The athlete should then be reassessed at regular intervals until pain, paresthesias, weakness, and all neurologic abnormalities have completely resolved.

Return to sport should occur only when the examination is normal and the athlete can perform sport-specific activities without recurrence.

Orthopaedic Surgery - Bunion/Hallux Valgus

Basics

A bunion is a prominent enlargement of the medial aspect of the first metatarsal head, often accompanied by overlying soft-tissue and bursal swelling.

Hallux valgus is a deformity centered mainly at the first metatarsophalangeal (MTP) joint. It consists of lateral deviation of the great toe together with medial deviation of the first metatarsal.

As the deformity progresses, subluxation or incongruity of the first MTP joint may develop.

General Prevention

Avoidance of narrow or constricting footwear may reduce symptoms and potentially limit progression in susceptible individuals.

Shoes with adequate width in the toe box are preferable.

Epidemiology

Hallux valgus occurs most commonly in middle-aged and older women, although adolescents and young adults may also be affected.

Females are affected more frequently than males.

The condition is seen predominantly in populations that routinely wear shoes and is much less common in traditionally unshod populations.

Prevalence

Hallux valgus affects approximately 23% of adults between 18 and 65 years of age.

Among adults older than 65 years, prevalence rises to approximately 35%.

Risk Factors

Important risk factors include heredity and footwear.

A positive family history is common, suggesting an inherited predisposition in many patients.

Narrow shoes and high heels may aggravate the deformity by increasing pressure across the forefoot and first MTP joint.

Genetics

A definite single genetic abnormality has not been identified.

However, approximately two-thirds of affected patients report a positive family history, indicating a substantial hereditary contribution.

Hallux valgus is also frequently associated with generalized ligamentous laxity syndromes, which themselves may have a genetic component.

Etiology

The development of hallux valgus is multifactorial.

Footwear with a narrow toe box or elevated heel is strongly associated with the condition.

Epidemiologic studies demonstrate a greater prevalence in shoe-wearing populations and increasing frequency when previously unshod societies adopt Western-style footwear.

Pes Planus

Pes planus may contribute to hallux valgus in some patients.

A pronated gait can alter mechanical loading through the first MTP joint and may increase stress on the medial column of the foot.

Flatfoot may also occur as part of a generalized ligamentous laxity pattern.

Metatarsus Primus Varus

Metatarsus primus varus, in which the first metatarsal deviates medially relative to the second, is strongly associated with hallux valgus.

As the angle between the first and second metatarsals increases, the risk and severity of hallux valgus also tend to increase.

Acquired Joint Laxity

Acquired ligamentous laxity can also contribute to deformity.

Conditions such as rheumatoid arthritis, gout, and previous trauma may weaken the soft-tissue restraints around the first MTP joint.

This allows progressive displacement of the first metatarsal and great toe.

Other Associated Factors

Other conditions that may contribute include amputation of another toe, severe lesser-toe deformities, and Achilles tendon contracture.

These conditions can alter forefoot biomechanics and increase abnormal pressure through the first ray.

Diagnosis

Signs and Symptoms

The most common symptom is pain over the medial eminence, usually caused by pressure from footwear.

The great toe deviates laterally, while the medial aspect of the first metatarsal becomes increasingly prominent.

The deformity may become more obvious during weight-bearing.

Shoe-Wear Problems

Many patients have difficulty finding comfortable footwear.

Pressure from the shoe over the medial bunion may produce irritation, redness, callus formation, or bursitis.

Cosmetic concern is also common, although appearance alone is not usually an indication for surgery.

Second-Toe Problems

In more advanced deformity, the great toe may impinge on or displace the second toe.

This can result in second-toe pain, hammering, crossover deformity, or other lesser-toe abnormalities.

Transfer Metatarsalgia

Hallux valgus may alter normal load distribution across the forefoot.

Patients can develop painful plantar callosities beneath the second metatarsal head, a condition often described as transfer metatarsalgia.

Pain may also arise directly from the first MTP joint, particularly when arthritis develops.

Physical Examination

The patient should be examined both sitting and standing because weight-bearing can accentuate the deformity.

The examiner should evaluate alignment of the great toe, first metatarsal, lesser toes, longitudinal arch, and hindfoot.

Achilles and Gastrocnemius Contracture

Ankle dorsiflexion should be assessed with the knee both flexed and extended.

Restricted dorsiflexion may indicate gastrocnemius or Achilles tendon contracture.

These contractures can contribute to abnormal forefoot loading.

Joint Motion

Motion should be assessed at the ankle, subtalar joint, midfoot, first tarsometatarsal joint, and MTP joints.

Restriction, crepitus, or pain at the first MTP joint may indicate associated arthrosis.

First-Ray Hypermobility

The first tarsometatarsal joint should be evaluated for excessive mobility or instability.

Vertical shear or manual stress can be used to assess the first ray.

Many patients with hallux valgus demonstrate some degree of first-ray hypermobility.

Flexibility of the Deformity

The examiner should determine whether the hallux valgus deformity can be manually corrected.

A flexible deformity is generally easier to treat than a rigid or fixed deformity.

The reducibility of the MTP joint is an important factor in surgical planning.

Foot Morphology

The overall shape of the foot and the status of the longitudinal arch should be documented.

Pes planus, metatarsus primus varus, lesser-toe deformities, and hindfoot malalignment may influence both symptoms and treatment.

Neurovascular Examination

A complete musculoskeletal and neurovascular examination of the lower extremity should be performed.

Peripheral vascular disease or neuropathy may substantially influence the safety and success of surgery.

Imaging

Weight-Bearing Radiographs

Standard evaluation includes standing anteroposterior, oblique, lateral, and axial sesamoid views of the foot.

Weight-bearing radiographs are essential because the deformity may appear less severe when the foot is unloaded.

Hallux Valgus Angle

The hallux valgus angle is measured between the longitudinal axes of the first metatarsal and proximal phalanx.

A normal value is generally less than 15°.

Increasing values indicate greater lateral deviation of the great toe.

Intermetatarsal Angle

The angle between the first and second metatarsals is used to assess metatarsus primus varus.

A normal first-second intermetatarsal angle is less than approximately 9°.

An increased angle is an important determinant of deformity severity and procedure selection.

Hallux Interphalangeal Angle

The hallux interphalangeal angle assesses alignment within the great toe itself.

A normal value is generally less than approximately 10°.

An increased angle may indicate hallux valgus interphalangeus and can influence the need for proximal phalanx osteotomy.

Distal Metatarsal Articular Angle

The distal metatarsal articular angle evaluates orientation of the first metatarsal head articular surface.

A normal value is approximately less than 10°.

An abnormal lateral slope can be associated with a congruent form of hallux valgus.

Sesamoid Position

Radiographs should assess displacement of the sesamoids relative to the first metatarsal head.

With progressive hallux valgus, the first metatarsal head shifts medially while the sesamoid complex remains relatively fixed.

This produces apparent lateral displacement of the sesamoids beneath the metatarsal head.

Joint Congruity and Arthritis

The first MTP joint should be assessed for congruity, subluxation, cartilage loss, osteophytes, and other degenerative changes.

These findings have a major influence on treatment selection.

Lesser-Toe Alignment

Radiographs should also evaluate the lesser toes for associated deformities.

Second-toe displacement, hammering, crossover deformity, or metatarsalgia may require simultaneous treatment.

Pathoanatomy

Hallux valgus is a three-dimensional deformity involving not only the first MTP joint but also the first tarsometatarsal joint and other components of the first ray.

The deformity can broadly be divided into congruent and incongruent types.

Incongruent Hallux Valgus

In an incongruent deformity, multiple static and dynamic abnormalities are present.

The first metatarsal drifts medially, increasing the intermetatarsal angle.

As the metatarsal head moves medially, the sesamoid complex remains relatively fixed by the transverse metatarsal ligament.

Dynamic Soft-Tissue Imbalance

As deformity progresses, the line of pull of the adductor hallucis, flexor hallucis brevis, extensor hallucis longus, and abductor hallucis becomes increasingly lateralized.

This further pulls the great toe into valgus and reinforces the deformity.

Capsular Changes

The medial capsule and ligaments become stretched and attenuated, while lateral soft tissues become progressively contracted.

These changes make the deformity increasingly difficult to correct manually as it advances.

Congruent Hallux Valgus

In congruent hallux valgus, the MTP joint remains anatomically congruent.

The articular surface may be abnormally sloped laterally, allowing the toe to remain aligned with the joint surface despite valgus orientation.

Because there is no pathologic joint subluxation, progression may be less pronounced than in an incongruent deformity.

Differential Diagnosis

The principal differential diagnosis is gout, which can produce pain, swelling, and prominence around the first MTP joint.

Acute gout usually presents with marked inflammation, redness, and tenderness rather than a gradually progressive structural deformity.

Treatment

General Measures

Hallux valgus should initially be treated with nonoperative measures.

Treatment is directed primarily toward reducing pain and improving shoe tolerance rather than correcting the structural deformity.

Footwear Modification

Proper footwear is one of the most important conservative measures.

Patients should avoid pointed shoes and high heels.

Lace-up shoes and styles with a wide toe box provide more space for the forefoot.

Shoe Adaptation

Soft leather shoes can sometimes be stretched over the medial bunion.

Shoes should ideally have no seam or stitching directly over the medial prominence.

Prescription footwear with additional width and depth may be required in severe cases.

Padding and Splints

Commercial pads, cushions, bunion sleeves, and splinting devices may reduce pressure over the medial eminence.

These devices can improve comfort but generally do not permanently correct the underlying deformity.

Orthotic Support

Patients with associated pes planus may benefit from custom or supportive orthoses.

Heel-cord stretching may be beneficial when Achilles or gastrocnemius tightness contributes to abnormal forefoot loading.

Physical Therapy

Physical therapy is usually of limited value for correcting the structural deformity or providing major long-term symptom relief.

Stretching may still be useful when there is an associated gastrocnemius or Achilles contracture.

Medication

Analgesic medications may be used for symptomatic relief.

NSAIDs or other simple analgesics can help when pain is associated with local inflammation or arthritis.

Goals of Surgery

The goals of operative treatment are pain relief, correction of deformity, restoration of more normal foot biomechanics, and preservation of useful joint motion whenever possible.

Procedure selection must be individualized.

Indications for Surgery

Surgery may be considered when there is persistent pain despite appropriate nonoperative treatment, progressive deformity, reduced function, or inability to tolerate reasonable footwear.

The severity of the deformity should be considered together with the patient’s symptoms.

Contraindications to Surgery

Surgery should generally not be performed for cosmetic concerns alone in an otherwise asymptomatic patient.

Significant vascular insufficiency is also a major contraindication because of the increased risk of poor wound healing and infection.

Surgical Decision-Making

Procedure selection depends on several factors, including patient age, severity of the intermetatarsal and hallux valgus angles, joint congruity, first-ray stability, arthritis, rigidity of the deformity, and associated lesser-toe pathology.

Numerous operative procedures have been developed because no single technique is appropriate for every patient.

Soft-Tissue Procedures

Soft-tissue procedures aim to rebalance the structures around the first MTP joint.

They may include release of contracted lateral tissues and tightening of the attenuated medial capsule.

These procedures are often combined with a metatarsal osteotomy.

Modified McBride Procedure

The modified McBride procedure may be used for selected mild deformities, usually as part of a combined correction.

It involves removal of the medial eminence, release of contracted lateral structures such as the adductor hallucis and lateral capsule, and tightening of the medial capsule.

Its purpose is to improve alignment and restore joint congruity.

Limitations of the Modified McBride Procedure

Soft-tissue correction alone may not adequately correct an increased intermetatarsal angle.

For this reason, the procedure is often combined with a metatarsal osteotomy.

Potential complications include overcorrection into hallux varus and joint stiffness.

Distal Chevron Osteotomy

A distal metatarsal chevron osteotomy involves a V-shaped cut near the metatarsal head.

The distal fragment is translated laterally to reduce the intermetatarsal angle and correct the deformity.

This procedure is most appropriate for mild to moderate hallux valgus.

Complications of Distal Chevron Osteotomy

Potential complications include malunion, osteonecrosis of the metatarsal head, stiffness, and hallux varus from overcorrection.

It generally provides insufficient correction for severe deformity.

Proximal Metatarsal Osteotomy

Proximal metatarsal osteotomy is generally reserved for moderate to severe deformity, particularly when the intermetatarsal angle is significantly increased.

The main purpose is to realign the first metatarsal relative to the second.

Types of Proximal Osteotomy

Several configurations have been described, including crescentic, oblique, opening-wedge, proximal chevron, Ludloff, and Scarf osteotomies.

These procedures may be combined with distal soft-tissue correction at the MTP joint.

Recurrence After Proximal Osteotomy

Recurrence after proximal metatarsal osteotomy has been reported in approximately 4–25% of cases.

Postoperative alignment and the quality of correction influence the risk of recurrent deformity.

Double Osteotomy

A double osteotomy combines proximal and distal correction.

It may be considered for severe hallux valgus when substantial angular correction is required.

One option combines a distal chevron with a proximal opening-wedge osteotomy.

Proximal Phalanx Osteotomy

Osteotomy of the proximal phalanx is used mainly for hallux valgus interphalangeus or as an additional procedure when metatarsal correction alone does not adequately align the great toe.

Akin Osteotomy

The Akin osteotomy is a medial closing-wedge osteotomy of the proximal phalanx.

It corrects valgus alignment within the great toe itself.

It is frequently performed in combination with another hallux valgus procedure.

Minimally Invasive Akin Osteotomy

Percutaneous and minimally invasive techniques have also been developed.

In selected patients, a minimally invasive Akin osteotomy can provide effective correction, sometimes without formal internal fixation.

Lapidus Procedure

The Lapidus procedure consists of fusion of the first tarsometatarsal joint combined with correction of the hallux valgus deformity.

It is particularly appropriate when there is hypermobility or instability of the first tarsometatarsal joint, significant metatarsus primus varus, or arthritis of the first TMT joint.

Effect of the Lapidus Procedure

By stabilizing and realigning the first ray, the Lapidus procedure can substantially reduce the intermetatarsal angle.

It is commonly used for moderate to severe deformities associated with first-ray instability.

First MTP Arthrodesis

Fusion of the first MTP joint may be appropriate for severe deformity, significant degenerative or inflammatory arthritis, connective tissue disorders, spasticity, or failed previous hallux valgus surgery.

It is also commonly considered in older patients with advanced joint destruction.

Results of MTP Fusion

MTP arthrodesis provides reliable pain relief and high patient satisfaction.

Its main disadvantage is permanent loss of motion at the first MTP joint.

However, many patients tolerate this well when the toe is fused in an appropriate functional position.

Prosthetic Arthroplasty

Joint replacement has been proposed as an alternative to fusion for arthritic first MTP joints.

However, prosthetic implants have historically demonstrated relatively high complication and failure rates.

They are generally used cautiously, particularly in younger or highly active individuals.

Keller Resection Arthroplasty

The Keller procedure involves removal of the medial eminence together with resection of part of the base of the proximal phalanx.

It is generally reserved for older, low-demand, sedentary patients.

Complications of Keller Arthroplasty

Potential problems include recurrent valgus deformity, transfer metatarsalgia, weakness of push-off, and cock-up deformity of the great toe.

Because of these limitations, it is rarely selected for younger or active patients.

Follow-Up

Patients treated nonoperatively should be reassessed if symptoms worsen, shoe tolerance decreases, or the deformity progresses.

Following surgery, clinical and radiographic follow-up is used to monitor wound healing, alignment, bone union, joint motion, and recurrence.

Prognosis

Mild and congruent deformities generally progress more slowly with conservative treatment than severe or incongruent deformities.

Nonoperative treatment can relieve symptoms but usually does not reverse the structural deformity.

Prognosis After Surgery

When surgery is performed for appropriate indications and the procedure is correctly matched to the deformity, most patients experience substantial pain relief and improvement in alignment.

Outcome depends on deformity severity, joint condition, procedure selection, and adherence to postoperative rehabilitation.

Complications

Potential surgical complications include wound breakdown, infection, recurrence of hallux valgus, overcorrection into hallux varus, malunion or nonunion, joint stiffness, neuroma formation, and transfer metatarsalgia.

Recurrence

Recurrent deformity may develop if the underlying metatarsal alignment, first-ray instability, or soft-tissue imbalance is not adequately corrected.

More severe initial deformities generally carry a higher risk of recurrence.

Hallux Varus

Excessive correction may produce hallux varus, in which the great toe deviates medially.

This can be painful and functionally limiting and may require additional treatment.

Transfer Metatarsalgia

Altered first-ray loading after surgery can shift excessive pressure to the lesser metatarsal heads.

This may produce persistent forefoot pain or plantar callosities, particularly beneath the second metatarsal.

Patient Monitoring

Patients should be monitored for progression of pain, changes in shoe tolerance, increasing deformity, development of lesser-toe problems, and signs of first MTP arthritis.

After surgery, follow-up should also assess wound healing, correction of alignment, bone union, joint motion, and recurrence of the deformity.