Oxford Textbooks

♦ Use of absorbable fracture fixation devices eliminates hardware removal procedures

♦ Of the macromolecular biodegradable compounds, suited for the manufacturing of these implants, polylactide is the most widely used

♦ Small-fragment intra-articular fractures, especially at the elbow and at the ankle, are the most rewarding clinical applications

♦ Absorbable implants can be inserted through articular surfaces and, in children, also transphyseally

♦ Mechanical failures of the implants and redisplacements of fractures are rare, but local, transient inflammatory foreign-body reactions occurr

♦ In certain intra-articular applications the absorbable fixation devices are superior to metallic ones.

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♦ The acromioclavicular joint is the sole skeletal connection between the upper limb and the axial skeleton, providing strength and stability to the shoulder

♦ The acromioclavicular joint is one of the most commonly injured joints of the body

♦ Arthropathy of the joint is often associated with contact sport or heavy manual work

♦ Treatment of arthropathy can either be by activity modification, steroid injection or surgery

♦ Surgery involves removing the distal end of the clavicle

♦ Dislocations of the acromioclavicular joint are common injuries, most often due to a fall landing directly on the tip of the shoulder

♦ Dislocations are classified into six grades (I to VI), grades I and II are treated non-surgically, grades IV-VI are treated surgically

♦ Numerous surgical options are available for treatment of acute and chronic dislocations

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♦ Bacteraemia resulting in bone deposition of bacteria

♦ Local bony tenderness, fever, and malaise may not be present initially

♦ WCC may be normal, ESR and CRP normally raised

♦ Plain radiographs normally take 10–12 days to occur

♦ Staphylococcus aureus remains the commonest organism

♦ Immediate antibiotics with surgical drainage of abscess formation.

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♦ Amputation surgery should produce a new end-organ for locomotion with a prosthesis or interaction with the environment

♦ The choice of amputation level should be based on healing, functional expectations, and prosthetic use

♦ Success of rehabilitation depends on multi-disciplinary input and management of complications

♦ The prostheses prescribed should depend on functional need and expectation.

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♦ The aims of the bone tumour surgeon are to improve survival and maintain optimal function of the patient; this can be achieved by amputation or limb salvage

♦ Limb salvage provides no greater risk to the survival of the patient than with amputation

♦ Reconstruction after removal of the tumour is commonly achieved by using endoprosthetic replacements, autografts, or massive allografts

♦ Complications of limb salvage include infection and difficulties associated with soft tissue reattachment and coverage of the bone replacement.

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It is apparent that the ‘pain pathway’ is not a static, hard-wired component of the nervous system, but is a very dynamic one. Both the nature of the peripheral stimulus and the degree of tissue damage can influence the level of neuronal activity and even the actual phenotype of the primary sensory neurone. This in turn can have major effects on signal processing at spinal level, initiating long-term changes within the spinal cord which alter all subsequent processing of sensory information. Any attempt to produce analgesia with local anaesthetics or other agents which act at the various accessible points in the pathway (Figure 2.7) must therefore take account of the changes which may already have occurred, and also of the possibility of preventing the development of detrimental long-term changes. Clinical implementation of the theory of ‘pre-emptive analgesia’, that is, inducing impulse block prior to injury to prevent the initiation and development of peripheral and central sensitization, remains controversial. Much of the work from animal studies supports the effectiveness of pre-treatment, but the results from clinical studies have been disappointing (Dahl & Moiniche 2004, Kissin 2000), perhaps because of the complexity and plasticity of the system. It is now clear that a multiplicity of neurotransmitters are involved at a variety of sites so that use of a single agent is almost bound to fail. It has become evident, therefore, that optimal analgesia can only be obtained by using a ‘balanced’ or ‘multi-modal’ approach (Kehlet & Dahl 1993), that is, systemic analgesics (e.g. opioids and non-steroidal anti-inflammatory drugs) combined with site-directed local anaesthetics (Wilmore & Kehlet 2001). ...Less

This chapter covers the anatomy and physiology of the vertebral canal. It begins with a description of the vertebral column, including its function and regions. The general features of vertebrae are described, along with those of the cervical vertebrae, thoracic vertebrae, lumbar vertebrae, and the sacrum and sacral canal. Variations in the bony anatomy of the spine (vertebral anomalies) are of particular interest because they may make the performance of spinal or epidural block difficult or impossible. Common anomalies are covered. The individual vertebrae articulate with each other through the column of bodies and intervertebral discs. Additionally, the neural arches articulate through the superior and inferior processes on each side at the zygapophysial joints. The chapter covers the ligaments of the vertebral bodies, and also the ligaments of the neural arches, spines, and transverse processes. There is information on the intervertebral discs and the vertebral canal, including the meninges and dural sac, subarachnoid space and spinal cord, spinal cord blood supply, and epidural space. Finally the physiology of the vertebral canal is discussed, including the cerebrospinal fluid and epidural pressure. ...Less

♦ Hind foot arthritis is usually treated orthotically but may need surgical fusion

♦ Severe ankle arthritis requiring surgical intervention is uncommon

♦ Arthroscopic debridement of early ankle arthritis is effective

♦ End stage ankle arthritis can be treated by fusion or arthroplasty

♦ Ankle replacement has a higher failure rate than hip or knee arthroplasty

♦ Correct alignment of the hind foot and forefoot are essential for good results.

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♦ Ankle fracture management is dependent on the patient, stability and congruence

♦ Comparative studies of treatment options should be interpreted with caution.

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♦ The development of safe and reliable approaches has allowed hip replacement surgery to be undertaken successfully

♦ There are four main approaches, each with their inherent advantages and disadvantages

♦ Awareness of the structures at risk with each approach reduces the risk of iatrogenic injury

♦ All of the approaches have been modified and improved upon to address specific weaknesses.

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