Ebook Essentials of musculoskeletal care (4/E): Part 1

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American Academy of Orthopaedic Surgeons
American Academy of Pediatrics

Essentials
of

Musculoskeletal

Care

John F. Sarwark, MD
Editor

E s s E n t i a l s o f M u s c u l o s k E l E ta l c a r E

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Board of Directors, 2010-2011
JohnJ.Callaghan,MD
President
DanielJ.Berry,MD
First Vice-President
JohnR.Tongue,MD
Second Vice-President
FrederickM.Azar,MD
Treasurer
JosephD.Zuckerman,MD
Past-President
JeffreyO.Anglen,MD
RichardJ.Barry,MD
KevinP.Black,MD
M.BradfordHenley,MD,MBA
GregoryA.Mencio,MD
MichaelL.Parks,MD
FredC.Redfern,MD
DavidD.Teuscher,MD
PaulTornettaIII,MD
DanielW.White,MD,LTC,MC
G.ZacharyWilhoit,MS,MBA
KarenL.Hackett,FACHE,CAE(Ex-Officio)

Staff
MarkW.Wieting
Chief Education Officer
MarilynL.Fox,PhD
Director, Department of Publications

LaurieBraun
Managing Editor
StevenKellert
Senior Editor
MarySteermannBishop
Senior Manager, Production and Archives
CourtneyAstle
Assistant Production Manager
SusanMorritzBaim
Production Coordinator
SuzanneO’Reilly
Graphic Designer
AnneRaci
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JaneBaque
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KatharineZoëGraham
Manager, Website Program Systems and Design
ReidStanton
Manager, Electronic Media

BrianMoore
Senior Media Producer
E s s E n t i a l s o f M u s c u l o s k E l E ta l c a r E

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Published2010bythe
AmericanAcademyofOrthopaedicSurgeons
6300NorthRiverRoad
Rosemont,IL60018
FourthEdition
Copyright2010
bytheAmericanAcademyofOrthopaedicSurgeons
ThematerialpresentedinEssentials of Musculoskeletal Care,Fourth
Edition,hasbeenmadeavailablebytheAmericanAcademyof
OrthopaedicSurgeonsforeducationalpurposesonly.Thismaterialisnot
intendedtopresenttheonly,ornecessarilybest,methodsorprocedures
forthemedicalsituationsdiscussed,butratherisintendedtorepresent
anapproach,view,statement,oropinionoftheauthor(s)orproducer(s),
whichmaybehelpfultootherswhofacesimilarsituations.The
recommendationsinthispublicationdonotindicateanexclusivecourse
oftreatmentorserveasastandardofmedicalcare.Variations,takinginto
accountindividualcircumstances,maybeappropriate.
SomedrugsormedicaldevicesdemonstratedinAcademycoursesor
describedinAcademyprintorelectronicpublicationshavenotbeen
clearedbytheFoodandDrugAdministration(FDA)orhavebeencleared
forspecificusesonly.TheFDAhasstatedthatitistheresponsibility
ofthephysiciantodeterminetheFDAclearancestatusofeachdrugor
deviceheorshewishestouseinclinicalpractice.
Furthermore,anystatementsaboutcommercialproductsaresolelythe

opinion(s)oftheauthor(s)anddonotrepresentanAcademyendorsement
orevaluationoftheseproducts.Thesestatementsmaynotbeusedin
advertisingorforanycommercialpurpose.
CPT®iscopyright2010AmericanMedicalAssociation.Allrights
reserved.Nofeeschedules,basicunits,relativevalues,orrelatedlistings
areincludedinCPT.TheAMAassumesnoliabilityforthedatacontained
herein.
Allrightsreserved.Nopartofthispublicationmaybereproduced,
storedinaretrievalsystem,ortransmitted,inanyform,orbyanymeans,
electronic,mechanical,photocopying,recording,orotherwise,without
priorwrittenpermissionfromthepublisher.
ISBN978-0-89203-579-3
PrintedintheUSA
Cover art
RobertLiberace
Anatomic Illustrations
ScottThornBarrows,MA,CMI,FAMI

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Essentials of Musculoskeletal Care, 4th Edition
Editorial Board
John F. Sarwark, MD

Professor
Department of Orthopaedic Surgery
Northwestern University
Feinberg School of Medicine
Chicago, Illinois
Michael Huxford, MEd, ATC, CSCS
Sports Medicine Coordinator
Rehabilitative Services
Institute for Sports Medicine
Children’s Memorial Hospital
Chicago, Illinois

April D. Armstrong, MD
Associate Professor
Bone and Joint Institute
Penn State Milton S. Hershey Medical Center
Hershey, Pennsylvania
Jerome M. Benavides, MD, MBA
Orthopaedic Surgeon
Foot and Ankle Center of South Texas
San Antonio, Texas

Jason L. Koh, MD
Vice-Chairman
Department of Orthopaedic Surgery
NorthShore University Health System
University of Chicago
Evanston, Illinois

Thomas O. Clanton, MD

Chief, Foot and Ankle Section
The Steadman Clinic – Vail
Vail, Colorado

John G. Seiler III, MD
Georgia Hand Shoulder & Elbow
Atlanta, Georgia

Craig J. Della Valle, MD
Associate Professor
Department of Orthopaedic Surgery
Rush University Medical Center
Chicago, Illinois

Dan M. Spengler, MD
Professor and Chair
Department of Orthopaedics and Rehabilitation
Vanderbilt Orthopaedic Institute
Nashville, Tennessee

Leesa M. Galatz, MD
Associate Professor
Shoulder and Elbow Service
Department of Orthopaedic Surgery
Washington University School of Medicine
St. Louis, Missouri

David A. Spiegel, MD
Pediatric Orthopaedic Surgeon
Children’s Hospital of Philadelphia

Assistant Professor of Orthopaedic Surgery
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Letha Y. Griffin, MD, PhD
Team Physician
Georgia State University
Department of Sports Medicine
Peachtree Orthopaedic Clinic
Atlanta, Georgia

Kathleen Weber, MD, MS
Assistant Professor
Department of Orthopaedic and Internal Medicine
Rush University Medical Center
Chicago, Illinois

Review Board

Section on Orthopaedics
Keith R. Gabriel, MD
Associate Professor
Department of Surgery
Southern Illinois University School of Medicine
Springfield, Illinois

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Council on Sports Medicine and Fitness
Blaise A. Nemeth, MD, MS
Assistant Professor (CHS)
Department of Orthopaedics and Rehabilitation
Department of Pediatrics
American Family Children’s Hospital
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin

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EditorialBoardDisclosures
NeitherDr.Armstrongnoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.
NeitherDr.Benavidesnoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.
Dr.Clantonoranimmediatefamilymemberservesasan
unpaidconsultanttoArthrex.
Dr.DellaValleoranimmediatefamilymemberservesas

aboardmember,owner,officer,orcommitteememberof
theAmericanAssociationofHipandKneeSurgeonsand
theArthritisFoundation;servesasapaidconsultanttoor
isanemployeeofBiomet,Kinamed,Smith&Nephew,
andZimmer;hasreceivedresearchorinstitutionalsupport
fromZimmer;andhasreceivednonincomesupport(suchas
equipmentorservices),commerciallyderivedhonoraria,or
othernon–research-relatedfunding(suchaspaidtravel)from
Stryker.
Dr.Galatzoranimmediatefamilymemberservesasan
unpaidconsultanttoTornierandhasreceivedresearch
orinstitutionalsupportfromBiomet,Breg,Cerapedics,
Medtronic,Smith&Nephew,Stryker,Synthes,Wright
MedicalTechnology,Wyeth,AxialBiotech,MidwestStone
Institute,andK2M.
Dr.Griffinoranimmediatefamilymemberservesasa
boardmember,owner,officer,orcommitteememberofthe
PiedmontHospital,GeorgiaStateUniversityAthleticBoard,
andtheAmericanOrthopaedicSocietyforSportsMedicine.

Dr.Kohoranimmediatefamilymemberservesasaboard
member,owner,officer,orcommitteememberoftheIllinois
AssociationofOrthopaedicSurgeons;isamemberofa
speakers’bureauorhasmadepaidpresentationsonbehalfof
Aesculap/B.BraunandArthrex;servesasapaidconsultantto
orisanemployeeofAesculap/B.BraunandArthrex;andhas
receivedresearchorinstitutionalsupportfromAesculap/B.
Braun,Arthrex,andEnturia.
NeitherDr.Sarwarknoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina

commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.
Dr.Seileroranimmediatefamilymemberservesasa
boardmember,owner,officer,orcommitteememberof
theAmericanBoardofOrthopaedicSurgery;hasreceived
royaltiesfromSalumedica;servesasanunpaidconsultantto
SynthesandArthrex;hasreceivedresearchorinstitutional
supportfromAvance;andownsstockorstockoptionsin
Orthovita.
Dr.Spengleroranimmediatefamilymemberservesasa
boardmember,owner,officer,orcommitteememberofthe
MusculoskeletalTransplantFoundation.
Dr.Spiegeloranimmediatefamilymemberservesasa
boardmember,owner,officer,orcommitteememberofthe
PediatricOrthopaedicSocietyofNorthAmerica.
Dr.Weberoranimmediatefamilymemberownsstockor
stockoptionsinPfizer.

NeitherMr.Huxfordnoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.

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Contributors
Albert J. Aboulafia, MD, MBA
Co-Director of Sarcoma Services
Department of Orthopaedic Surgery
The Alvin & Lois Lapidus
Cancer Institute
Baltimore, Maryland
Lindsay Andras, MD
Orthopaedic Resident
Emory Orthopaedics
Emory University
Atlanta, Georgia
Sigurd H. Berven, MD
Rebecca Carl, MD
Professor of Pediatrics
Department of Orthopaedic Surgery
Northwestern University
Feinberg School of Medicine
Chicago, Illinois
Brian D. Dierckman, MD
Resident
Department of Orthopaedic Surgery
Emory University
Atlanta, Georgia

Julie A. Dodds, MD
Associate Clinical Professor
College of Human Medicine
Michigan State University
East Lansing, Michigan
Robert T. Floyd, EdD, ATC
Director of Athletic Training
and Sports Medicine
Chair and Professor of Physical
Education and Athletic Training
Department of Athletic Training
The University of West Alabama
Livingston, Alabama
Jordyn Griffin, BA
Medical Student
Medical College of Georgia
Augusta, Georgia
George N. Guild III, MD
Orthopaedic Surgeon
Department of Orthopaedic Surgery
Emory University
Atlanta, Georgia

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Stephen C. Hamilton, MD
Resident
Department of Orthopaedic Surgery
Emory University
Atlanta, Georgia

Kyle E. Hammond, MD
Resident Physician
Department of Orthopaedic Surgery
Emory University
Atlanta, Georgia
James S. Kercher, MD
Department of Orthopaedic Surgery
Emory University
Atlanta, Georgia
Yukiko Kimura, MD
Chief of Pediatric Rheumatology
Joseph M. Sanzari Children’s Hospital
Hackensack University Medical Center
Hackensack, New Jersey
L. Andrew Koman, MD
Chair and Professor
Department of Orthopaedic Surgery
Wake Forest University
School of Medicine
Winston-Salem, North Carolina
Lindsey Snyder
Knowles, DPT, STC
Department of Outpatient
Orthopaedics and Sports
Physical Therapy
Atlanta Sport & Spine Physical
Therapy
Atlanta, Georgia
Joseph M. Lane, MD
Chief

Metabolic Bone Service
Department of Orthopaedics
Hospital for Special Surgery
New York, New York
Thomas J. Moore, MD
Associate Professor
Department of Orthopaedic Surgery
Emory University
Atlanta, Georgia

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Robert Murphy, MS, ATC
Assistant Athletic Director
for Sports Medicine
Department of Intercollegiate Athletics
Georgia State University
Atlanta, Georgia
Shane J. Nho, MD, MS
Assistant Professor
Section of Sports Medicine
Department of Orthopaedic Surgery
Rush University Medical Center
Chicago, Illinois
Michael S. Pinzur, MD
Professor of Orthopaedic Surgery

Department of Orthopaedic Surgery
Loyola University Health System
Maywood, Illinois
Michael S. Sridhar, MD
Resident
Department of Orthopaedic Surgery
Emory University
Atlanta, Georgia
Harlan M. Starr, MD
Resident Physician
Department of Orthopaedic Surgery
Emory University School of Medicine
Atlanta, Georgia
Brian L. Thomas, MD
Chairman
Department of Anesthesiology
Piedmont Hospital
Atlanta, Georgia
Lawrence Wells, MD
Attending Orthopaedic Surgeon
Department of Orthopaedic Surgery
The Children’s Hospital
of Philadelphia
Assistant Professor
of Orthopaedic Surgery
University of Pennsylvania School
of Medicine
Philadelphia, Pennsylvania

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Contributors’Disclosures
NeitherDr.Aboulafianoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.
Dr.Andrasoranimmediatefamilymemberhasreceived
researchorinstitutionalsupportfromOsteotechandowns
stockorstockoptionsinEliLilly.
Dr.Bervenoranimmediatefamilymemberservesasa
boardmember,owner,officer,orcommitteememberofthe
BoneandJointDecade,USA,theNorthAmericanSpine
Society,andtheScoliosisResearchSociety;servesasapaid
consultanttoorisanemployeeofAlphatecSpine,Biomet,
DePuy,MedtronicSofamorDanek,Osteotech,Stryker:
Pioneer;andUSSpine;hasreceivedresearchorinstitutional
supportfromOREFandtheAOFoundation;andownsstock
orstockoptionsinBaxano,Simpirica,Providence,Axis,and
AccuLif.
NeitherDr.Carlnoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.
Dr.Dierckmanoranimmediatefamilymemberhasreceived
researchorinstitutionalsupportfromSurgicalMonitoring
AssociatesandStrykerandhasreceivednonincomesupport
(suchasequipmentorservices),commerciallyderived

honoraria,orothernon–research-relatedfunding(suchaspaid
travel)fromSynthes.
Dr.Doddsoranimmediatefamilymemberservesasa
boardmember,owner,officer,orcommitteememberofthe
ArthroscopyAssociationofNorthAmericaandtheSaint
LawrenceOutpatientSurgeryCenter.
Mr.Floydoranimmediatefamilymemberservesasaboard
member,owner,officer,orcommitteememberoftheNational
AthleticTrainersAssociationandtheNationalAthletic
TrainersAssociationResearchandEducationFoundation.
Ms.Griffinoranimmediatefamilymemberservesasa
boardmember,owner,officer,orcommitteememberofthe
PiedmontHospital.
NeitherDr.Guildnoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.
NeitherDr.Hamiltonnoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.
NeitherDr.Hammondnoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.
NeitherDr.Kerchernoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.
Dr.Kimuraoranimmediatefamilymemberservesasa

boardmember,owner,officer,orcommitteememberofthe
ArthritisFoundation;hasreceivedroyaltiesfromOxford
UniversityPressandUpToDate;andhasreceivedresearchor
institutionalsupportfromRoche.

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Dr.Komanoranimmediatefamilymemberservesasa
boardmember,owner,officer,orcommitteememberofDT
ScimedandKeranetics;servesasapaidconsultanttooris
anemployeeofDTScimedandQRxPharma;hasreceived
researchorinstitutionalsupportfromDatatrace,Allergan,
Biomet,DTScimed,Johnson&Johnson,Keranetics,Smith&
Nephew,Synthes,WrightMedicalTechnology,andZimmer;
ownsstockorstockoptionsinWrightMedicalTechnology;
andhasreceivednonincomesupport(suchasequipmentor
services),commerciallyderivedhonoraria,orothernon–
research-relatedfunding(suchaspaidtravel)fromDatatrace,
DTScimed,andKeranetics.
NeitherDr.Knowlesnoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.
Dr.Laneoranimmediatefamilymemberisamemberofa
speakers’bureauorhasmadepaidpresentationsonbehalf
ofGlaxoSmithKline,EliLilly,Procter&Gamble,SanofiAventis,Novartis,andRoche;servesasapaidconsultanttoor

isanemployeeofBiomimetic,Orthovita,Osteotech,Zimmer,
InnovativeClinicalSolutions,D’Fine,Biomimetics,Soteria,
ZelosThearpeutics,andKuros;andhasreceivednonincome
support(suchasequipmentorservices),commercially
derivedhonoraria,orothernon–research-relatedfunding
(suchaspaidtravel)fromAmgen.
Dr.Mooreoranimmediatefamilymemberisamemberof
aspeakers’bureauorhasmadepaidpresentationsonbehalf
ofOsteotechandSynthes,servesasanunpaidconsultantto
Osteotech,andhasreceivedresearchorinstitutionalsupport
fromSynthes.
Dr.Murphyoranimmediatefamilymemberservesasaboard
member,owner,officer,orcommitteememberofCollege
AthleticTrainers’Societyandownsstockorstockoptionsin
Stryker.
Dr.Nhooranimmediatefamilymemberhasreceived
researchorinstitutionalsupportfromArthrex,DJ
Orthopaedics,Linvatec,Ossur,Smith&Nephew,Athletico,
andMiomed.
Dr.Pinzuroranimmediatefamilymemberisamemberof
aspeakers’bureauorhasmadepaidpresentationsonbehalf
ofSBI,Smith&Nephew,andAscension;servesasapaid
consultanttoorisanemployeeofSBIandSmith&Nephew;
andhasreceivedresearchorinstitutionalsupportfrom
SynthesandBiomimetic.
NeitherDr.Sridharnoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofhischapter.
NeitherDr.Starrnoranyimmediatefamilymember

hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication
NeitherDr.Thomasnoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.
NeitherDr.Wellsnoranyimmediatefamilymember
hasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyor
indirectlytothecontentofthispublication.

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Dedication
To health care providers everywhere—who devote their careers to the health
and well-being of individual patients and families, both young and old.

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Preface
Essentials of Musculoskeletal Carebridgesthegap
betweenwhatprimarycarephysiciansweretaughtin
medicalschoolandwhattheyneedtoknowtoevaluate
andmanagecommonmusculoskeletalconditions.This
textisusedforimmediate,point-of-careguidancein
decisionmakingandintervention.Physiciansandallied
healthcareprovidersalsooftenusetheimagesinthis
texttoeducatetheirpatientsregardingconditionsand
treatments.Essentialsalsohelpsphysiciansdecide
whichcasestotreatthemselvesandwhichtorefer.
SincethefirsteditionofEssentials of Musculoskeletal
Carewaspublishedin1997,morethan120,000copies
havebeensold.
Essentials of Musculoskeletal Careisusedby
physiciansinfamilypractice,internists,specialistsin
physicalmedicineandrehabilitation,pediatricians,
physiciansinthearmedforces,physiciansin
occupationalmedicine,physiciansinsportsmedicine,
athletictrainers,physicaltherapists,emergency
medicinephysicians,nursepractitioners,physician
assistants,residentsinfamilypracticeandorthopaedic
surgery,orthopaedicsurgeons,osteopathicphysicians,
andmanyothers.Inaddition,althoughnotdesignedas
atextbook,Essentialshasbeenadoptedasarequired
orrecommendedtextbynumerousteachingprograms,
bothforclinicalrotationsandforcoursessuchas
ConceptsinPrimaryCare,OrthopaedicInjuries,
PrimaryCareofAdults,andMusculoskeletalClinical
Medicine.

ThisfourtheditionofEssentials of Musculoskeletal
Carehasbeenimprovedandenhancedwithadditional
illustrations,tables,andvideoforevengreaterclarity
andeaseofreading.Allsectionsandchaptershave
beenreviewedandupdated,somecompletely,and
severalnewtopicshavebeenadded.Inaddition,
rehabilitationprescriptionswithhomeexercise
programsandgeneralmusculoskeletalconditioning
programsareavailableinthetextandaspatient
handoutsthatcanbeprintedfromtheDVDthat
accompaniesthisbook.EnhancementstotheDVDare

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extensive,includingtheinclusionofadultandpediatric
musculoskeletalphysicalexaminationsandtests.Also
newtothiseditionistheavailabilityofonlineaccessto
thecontentsofthebook.
IamindebtedtotheBoardofDirectorsofthe
AmericanAcademyofOrthopaedicSurgeons
(AAOS)andtotheexecutivestaffofAAOSfortheir
commitmenttoexcellenceineducation.Mythanks
alsogototheEditorialBoardforthisfourthedition
fortheircommitmenttothisproject:sectioneditors
LethaYurkoGriffin(GeneralOrthopaedics);Leesa
M.Galatz(Shoulder);AprilD.Armstrong(Elbow

andForearm);JohnG.SeilerIII(HandandWrist);
CraigJ.DellaValleandKathleenWeber(Hipand
Thigh);JasonL.Koh(KneeandLowerLeg);Jerome
M.BenavidesandThomasO.Clanton(Footand
Ankle);DanM.Spengler(Spine);DavidAndrew
Spiegel(PediatricOrthopaedics);andMichael
Huxford,whooversawtherehabilitationcontent.I
alsoamindebtedtothefollowingAAOSstaff:Laurie
Braun,ManagingEditor,andStevenKellert,Senior
Editor,whoworkeddiligentlytoensureanupdated
andaccurateprofessionalpublicationaccordingtoa
strictproductionschedule;MarilynFox,PhD,Director
ofPublications,whoseleadershipandlong-term
guidanceis“essential”;andMarySteermannBishop,
CourtneyAstle,SuzanneO’Reilly,andeveryoneinthe
PublicationsDepartmentwhocontributedtothedesign
andproductionofthisbook.
Onceagain,wearegratefulforthesupportofthe
AmericanAcademyofPediatrics(AAP)andthank
themforservingasavaluableprofessionalAcademy
partnerintheEssentialsproject.Thecommentsfrom
theAAPaswellasfromtheinternists,physiatrists,
familypractitioners,orthopaedicresidents,medical
students,andotherswhousethisbookhavehelpedus
continuouslyimprovethispublication.
JohnF.Sarwark,MD
Editor

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HowtoUse
Essentials of Musculoskeletal Care4thEdition
Essentials of Musculoskeletal Careprovidesconcisecontentinaneasy-to-useformat.Thebookchapters
arealsoavailableonline.Toaccesstheonlinecontent,followtheinstructionsprovidedontheinsidecover
ofthisbook.

PAIN DIAGRAM

SECTION 4

Hand and Wrist

Pain diagramopenseachsection.
Showsareasofpainandidentifies
conditionstypicallyassociatedwith
eachpainlocation.Nameschapter
whereconditionisdiscussed.

de Quervain tenosynovitis

Glomus tumor

Fracture of the scaphoid
Arthritis of the wrist
Arthritis of the thumb CMC joint

Boutonnière
deformity

Paronychia

(Tumors of the
Hand and Wrist)

Mucous cyst
(Tumors of the
Hand and Wrist)

(Fingertip Infection)

Osteoarthritis
(fingers)

Fracture of the base of the
thumb metacarpal

(Arthritis of the Hand)

Hand and Wrist
TBD Pain diagram

429 Arthritis of the Wrist

TBD Anatomy

431 Procedure: Wrist
Aspiration/Injection

399 Overview of the
Hand and Wrist
404 Physical
Examination of the
Hand and Wrist

Mallet finger

416 Animal Bites

Epidermal inclusion cyst

Sprained
collateral
ligament

(Tumors of the Hand and Wrist)

Table of contentslistsconditionsin
alphabeticorderandindicatestopics
withanaccompanyingvideoonthe
DVD.

Felon (Fingertip Infections)

Fracture of
the phalanges

Ulnar collateral
ligament tear

(Sprains and
Dislocations
of the Hand)

Rheumatoid arthritis

Flexor tendon
sheath ganglion

(Arthritis of the Hand)

419 Arthritis of the Hand
422 Procedure:
Metacarpophalangeal or Proximal
Interphalangeal
Joint Injection

443 de Quervain
Tenosynovitis
445 Procedure: de
Quervain Tenosynovitis Injection

424 Arthritis of the
Thumb Carpometacarpal Joint

447 Dupuytren

Contracture

427 Procedure: Thumb
Carpometacarpal
Joint Injection

455 Procedure: Digital
Anesthetic Block
(Hand)

450 Fingertip Infections

458 Fingertip Injuries/
Amputations
461 Flexor Tendon
Injuries

493 Procedure: Dorsal
Wrist Ganglion
Aspiration
495 Human Bite Wounds

465 Flexor Tendon
Sheath Infections

499 Kienböck Disease

468 Fracture of the
Base of the Thumb
Metacarpal

504 Nail Bed Injuries

471 Fracture of the Hook
of the Hamate
474 Fracture of the
Distal Radius
479 Fracture of the
Metacarpals and
Phalanges

501 Mallet Finger
507 Procedure: Fishhook
Removal
510 Sprains and
Dislocations of the
Hand
516 Trigger Finger
519 Procedure: Trigger
Finger Injection

484 Fracture of the
Scaphoid

521 Tumors of the Hand
and Wrist

488 Ganglion of the
Wrist and Hand

525 Ulnar Nerve
Entrapment at the
Wrist

Section Editor
John G. Seiler III, MD
Georgia Hand Shoulder & Elbow
Atlanta, GA

Fracture of
the metacarpals

Arthritis of
the thumb
CMC joint
Flexor tendon sheath
infection

436 Carpal Tunnel
Syndrome
441 Procedure: Carpal
Tunnel Injection

(Ganglia of the
Wrist and Hand)

Trigger finger

433 Boutonnière
Deformity

Michael Huxford, MEd, ATC, CSCS
Sports Medicine Coordinator
Rehabilitative Services
Institute for Sports Medicine
Children’s Memorial Hospital
Chicago, IL

Fracture of the scaphoid
Ganglia of the wrist and hand
Kienböck disease

Dupuytren disease
Fractures of the hook
of the hamate

Volar ganglion

Osteoarthritis

(Ganglia of the
Wrist and Hand)

Rheumatoid arthritis

Arthritis of the wrist
Ulnar nerve entrapment
at the wrist

(Arthritis of the Wrist)

Fracture of the distal radius
Carpal tunnel syndrome

AnAtomy of the hAnd And Wrist
Scaphoid
and
Tubercle

Lunate
Triquetrum

Trapezoid

Carpal
bones

Pisiform

Trapezium
and
Tubercle

Carpal
bones

Capitate
Hamate and
Hook
1

Sesamoid
bones

2

Base
Shafts
Head
3

4

Metacarpal bones

5
Right hand:
anterior (palmar) view
Base
Shafts
Head

Proximal phalanges

Base
Shafts
Head

Middle phalanges

Base
Shafts
Tuberosity
Head

Distal phalanges

Lunate
Scaphoid
Capitate

Carpal
bones

Anatomic artatbeginningofsection
forhandyreference.

Trapezoid
Carpal bones

Pisiform
Triquetrum
Hamate

Trapezium

1
Metacarpal bones

Base

Shafts
Head

5

4

3

2

Right hand:
posterior (dorsal) view

Proximal phalanges

Base
Shafts
Head

Middle phalanges

Base
Shafts
Head

Distal phalanges

Base
Shafts

Tuberosity
Head

Physical Examination
of the Hand and Wrist

Bones of the Wrist and Hand

Inspection/Palpation

A

Observe the alignment of the fingers.
Inspect the nails for pitting and other
evidence of systemic disorders. Look for
swelling and synovitis of the finger and
wrist joints. Note any osteophytes or bony
prominences associated with degenerative arthritis. Muscle atrophy between the
metacarpals is caused by weakness of the
intrinsic muscles.

B
Wrist Flexion and Extension: Zero
Starting Position

Dorsum

To measure wrist flexion and extension, a
goniometer is needed. Place the patient’s forearm in pronation and the carpus aligned with
the plane of the forearm. Place the goniometer

on the dorsum of the wrist or on the radial
side of the forearm (A). Aligning the goniC
ometer on the ulnar side may falsely elevate
the measurement because of the mobility of the fifth metacarpal. Wrist motion occurs at
the radiocarpal and midcarpal joints. Normal wrist palmar flexion (B) is 75° to 80°, and
normal dorsal extension (C) is 70° to 80°.

Palm
Look for atrophy of the thenar
muscles, which are innervated by the
median nerve, and the hypothenar
muscles, which are innervated by the
ulnar nerve. Note any thickening of
the palmar fascia associated with
Dupuytren contracture. Pain elicited
by pressure over the thumb metacarpophalangeal joint suggests arthritis
or instability of this joint. Position the
patient’s hands with the palms facing
each other to best visualize atrophy
of the thenar muscles. Swelling in the
joints of the thumb also is prominent
in this position.

Physical examinationshows
photographsandstep-by-step
descriptionsofphysicalexamination
maneuvers:inspectionandpalpation,
rangeofmotion,muscletesting,and
specialtests.Symbolindicatesthat
videosareavailableontheDVD.

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A

C

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B
Wrist Radial and Ulnar Deviation
To measure radial and ulnar deviation, a goniometer
is needed. Place the patient’s forearm in pronation
and the carpus aligned with the plane of the forearm.
Align the goniometer with the third metacarpal and
the axis of the forearm (A). In radial and ulnar deviation, the carpal rows move as linked segments. The
buttress of the radial styloid limits radial deviation
so that its arc of motion is significantly less. Normal
radial deviation (B) is 20° to 25°, and normal ulnar
deviation (C) is 35° to 40°.

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ARTHRITIS OF THE WRIST

Arthritis of the Wrist
712.23
Pseudogout of the wrist
714.0
Rheumatoid arthritis
715.13
Osteoarthritis of the wrist,
primary
715.23
Osteoarthritis of the wrist,
secondary
715.93
Osteoarthritis of the wrist,
unspecified
716.13
Traumatic arthropathy of the
wrist
716.92
Traumatic arthropathy
unspecified, forearm

■

Synovitis
Wrist joint arthritis

Septic arthritis of the wrist (acute onset, severe pain and
restriction of wrist motion, systemic signs of infection)

Tenosynovitis (normal radiographs, swelling over the
involved tendon)

SECTION 4 HAND AND WRIST

■

Synonym

ICD-9 Codes

SECTION 4 HAND AND WRIST

Conditions chapters include:
a. ICD-9codes
b. Synonyms
c. Clinicalsymptoms
d. Physicalexaminationpearls
e. Diagnostictests
f. Differentialdiagnosis
g. Adverseoutcomesofthedisease
h. Treatment
i. Rehabilitationprescription
j. Adverseoutcomesoftreatment
k. Referraldecisions/Redflags

Differential Diagnosis

Adverse Outcomes of the Disease

Definition

Pain, loss of motion and/or strength, and impaired function in
the wrist and fingers are possible.

Arthritis in the wrist most commonly occurs secondary to
previous trauma (eg, fractures of the distal radius) or rheumatoid
arthritis. Pseudogout and primary osteoarthritis also may affect
the wrist.

Treatment
Medical management depends on the type of arthritis present.
Temporary immobilization in a splint can help relieve pain
and swelling. In the absence of infection, injection of a
corticosteroid may provide temporary pain relief (see pages
431-432). Surgery is usually necessary when hand function
decreases, when the joint becomes unstable, or when nonsurgical
treatment fails to relieve pain. Surgical treatment usually focuses
on improving stability and limiting discomfort.

Clinical Symptoms
Patients with rheumatoid arthritis typically report generalized
swelling, tenderness, and limited motion. Hand function is often
impaired by the synovitis and resultant instability of the carpal
bones. The result is radial deviation of the wrist, ulnar deviation
of the fingers, inefficient wrist and finger tendon function,
decreased grip strength, and pain with daily activities.
Degenerative arthritis of the wrist is associated with swelling,
pain, and limited motion of the wrist.

Adverse Outcomes of Treatment
Loss of motion and persistent pain can develop. NSAIDs can
cause gastric, renal, or hepatic complications.

Tests

Figure 1 PA radiograph

showing osteoarthritis
of the wrist. Note the
subchondral sclerosis
of the radius and the
loss of radiocarpal
joint space (black
arrow). The
scapholunate interval
is also widened
(white arrow).

Physical Examination

Examination reveals swelling, increased warmth, limited motion,
and pain on palpation of the radiocarpal joint. Patients with
rheumatoid arthritis often have associated involvement of the
metacarpophalangeal joints and deformity at the wrist and
fingers. The ulna may appear prominent (caput ulnae).
In posttraumatic degenerative arthritis, the finger joints
usually appear normal.

Referral Decisions/Red Flags

Patients with a possible wrist infection require immediate
evaluation. Those with radiographic evidence of advanced
disease from degenerative or rheumatoid arthritis and those who
do not respond to splinting and NSAIDs also are candidates for
further evaluation.

Diagnostic Tests

PA and lateral radiographs are helpful in distinguishing the
various types of arthritis. Generalized thinning of the bone
structure (osteopenia) with erosions in the area of the joint
surface is characteristic of rheumatoid arthritis. Subchondral
sclerosis, joint space narrowing, spur formation, and, in some
cases, erosion characterize primary or secondary osteoarthritis
(Figure 1). Early calcification of the triangular fibrocartilage
complex may indicate pseudogout, which can be confirmed by
the presence of calcium pyrophosphate crystals in synovial fluid
aspirate.
Laboratory studies, including erythrocyte sedimentation rate
and tests for rheumatoid factor, antinuclear antibodies, and uric
acid, may help confirm the diagnosis.

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Apply heat to the hand for 15 minutes before performing the exercises, and apply ice (a bag of
crushed ice or frozen peas) to the hand for 20 minutes after each exercise session to prevent
inflammation.
If numbness steadily worsens, if the exercises increase the pain, or if the pain does not improve
after you have performed the exercises for 3 to 4 weeks, call your doctor.

Exercise Type
Nerve and tendon gliding

Targeted
Structure
Median nerve

Number of
Repetitions/Sets
10 to 15 repetitions

Number of

Days per Week

Number of
Weeks

6 to 7

3 to 4

Nerve and Tendon Gliding
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■

■

■

■

■
■

With the affected hand raised, make a fist
with the thumb outside the fingers (1).
Extend the fingers, keeping the thumb
close to the side of the hand (2).
Extend the hand at the wrist (bend it

backward, toward the forearm), keeping
the fingers straight (3).
With the wrist straight, extend the thumb
as shown (4).
Keeping the thumb extended, extend the
hand at the wrist (5).
Reach behind your hand and grasp the
thumb with the thumb and forefinger of
the opposite hand. Pull the thumb
downward, away from the palm of your
hand (6).
Repeat 10 to 15 times.
Perform the exercises 6 to 7 days a week,
for 3 to 4 weeks.

■

(Adapted with permission from Donatelli R, Wooden M,
eds: Orthopaedic Physical Therapy. Philadelphia, PA,
Elsevier, 2001.)

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Home exercise programincludes:
a. Symbolindicatingcustomizable
pdfofthehomeexercise
programisavailableontheDVD
andcanbeprintedfromyour
computer
b. Handytableofexercises

c. Step-by-stepinstructionsand
illustrations

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E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E

SECTION 4 HAND AND WRIST

Home Physical Therapy Program for Carpal Tunnel Syndrome

Procedure:
Digital Anesthetic
Block (Hand)
CPT Code
64450
Injection, anesthetic agent;
other peripheral nerve or
branch.
Current Procedural Terminology
© 2010 American Medical
Association. All rights reserved.

Materials
• Bactericidal skin preparation
solution
• 3-mL or 5-mL syringe with a
27-gauge needle

• 3 or 5 mL of 1% local
anesthetic without epinephrine

Proceduresinclude:
a. CPTcode(s)
b Symbolindicatingvideois
availableontheDVD
c. Listofmaterials
d. Step-by-stepinstructions

Technique 1: Dorsal Web Space Block
Step 1

Wear protective gloves at all times during this procedure and
use sterile technique.

Step 2

• Sterile gloves

• Sterile dressing

Note: Two techniques are shown. The dorsal web space block is
preferred by some because they believe the injection is less
painful for the patient. Others prefer the volar block because
they believe it is more effective.

Cleanse all surfaces of the base of the finger with a bactericidal
skin preparation solution.

Step 3

Draw 3 mL of the local anesthetic into the syringe.

Step 4

Insert the 27-gauge needle into the web space alongside the
extensor tendon (Figure 1). Advance the needle until it is almost
at the volar skin and inject 1 mL of the local anesthetic.

Figure 1 Dorsal location for needle

insertion into the web space
alongside the extensor tendon.

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Figure 2 Dorsal location for needle insertion

along the top of the extensor tendon.

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Association.Allrightsreserved.

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TableofContents
SECTION ONE

General Orthopaedics
xx PainDiagram

73 CrystalDepositionDiseases

145 LymeDisease

2 Anatomy

80 DeepVeinThrombosis

149 Osteoporosis

3 O

verviewofGeneral
Orthopaedics

87 D
iffuseIdiopathicSkeletal
Hyperostosis

158 OveruseSyndromes

8 P
rinciplesofMusculoskeletal
Evaluation

89 D
rugs:Corticosteroid
Injections

15 A
mputationsoftheLower
Extremity

92 Drugs:NSAIDs

169 P
reoperativeEvaluationof
MedicalComorbidities

96 F
allsandTraumaticInjuries
intheElderlyPatient

175 R
ehabilitationand
TherapeuticModalities

101 FibromyalgiaSyndrome

183 M
usculoskeletal
Conditioning:Helping
PatientsPreventInjury
andStayFit

25 A
nesthesiaforOrthopaedic
Surgery
32 Arthritis:Osteoarthritis
39 C
omplementaryand
AlternativeMedicine
TherapiesforOsteoarthritis
45 A
rthritis:Rheumatoid
Arthritis
52 A
rthritis:Seronegative
Spondyloarthropathies
58 CompartmentSyndrome

108 F

ractureEvaluationand
ManagementPrinciples
116 FractureHealing
120 FractureSplintingPrinciples
128 I maging:Principlesand
Techniques
137 Infection:Osteomyelitis
140 Infection:SepticArthritis

165 P
ain:NonorganicSymptoms
andSigns

219 R
ehabilitation:Canes,
Crutches,andWalkers
225 S
portsMedicineEvaluation
andManagementPrinciples
230 SprainsandStrains
235 TumorsofBone

67 C
omplexRegionalPain
Syndrome

SECTION TWO

Shoulder
242 PainDiagram

244 Anatomy
245 OverviewoftheShoulder
256 P
hysicalExaminationofthe
Shoulder

xiv

280 F
ractureofthe
HumeralShaft
283 F
ractureoftheProximal
Humerus
288 FractureoftheScapula

311 RotatorCuffTear
317 R
uptureoftheProximal
BicepsTendon
320 ShoulderInstability

263 AcromioclavicularInjuries

291 FrozenShoulder

269 ArthritisoftheShoulder

295 ImpingementSyndrome

325 P
rocedure:Reduction
ofAnteriorShoulder
Dislocation

273 B
urnersandOtherBrachial
PlexusInjuries

301 P
rocedure:Subacromial
BursaInjection

328 S
uperiorLabrumAnteriorto-PosteriorLesions

277 FractureoftheClavicle

303 O
verheadThrowing
ShoulderInjuries

333 ThoracicOutletSyndrome

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SECTION THREE

Elbow and Forearm
340 PainDiagram
342 Anatomy
343 O
verviewoftheElbowand
Forearm
347 P
hysicalExaminationof
theElbowandForearm
354 ArthritisoftheElbow
358 DislocationoftheElbow

361 F
ractureofthe
DistalHumerus

379 OlecranonBursitis

364 FractureoftheOlecranon

382 P
rocedure:OlecranonBursa
Aspiration

367 F
ractureofthe
RadialHead

384 N
erveCompression
Syndromes

370 L
ateralandMedial
Epicondylitis

389 R
uptureoftheDistal
BicepsTendon

377 P
rocedure:TennisElbow
Injection

392 U
lnarCollateral
LigamentTear

SECTION FOUR

Hand and Wrist
396 PainDiagram
398 Anatomy

441 Procedure:Carpal
TunnelInjection

484 FractureoftheScaphoid

443 deQuervainTenosynovitis

488 GanglionoftheWrist
andHand

445 Procedure:deQuervain
TenosynovitisInjection

493 Procedure:DorsalWrist
GanglionAspiration

447 DupuytrenContracture

495 HumanBiteWounds

416 AnimalBites

450 FingertipInfections

499 KienböckDisease

419 ArthritisoftheHand

455 Procedure:Digital

AnestheticBlock(Hand)

501 MalletFinger

458 FingertipInjuries/
Amputations

507 Procedure:Fishhook
Removal

461 FlexorTendonInjuries

510 SprainsandDislocations
oftheHand

399 O
verviewoftheHand
andWrist
404 P
hysicalExamination
oftheHandandWrist

422 P
rocedure:
Metacarpophalangealor
ProximalInterphalangeal
JointInjection

504 NailBedInjuries

424 A
rthritisoftheThumb
CarpometacarpalJoint

465 FlexorTendon
SheathInfections

427 Procedure:Thumb
CarpometacarpalJoint
Injection

468 FractureoftheBaseof
theThumbMetacarpal

519 Procedure:Trigger
FingerInjection

429 ArthritisoftheWrist

471 FractureoftheHookof
theHamate

431 Procedure:WristAspiration/
Injection

521 TumorsoftheHand
andWrist

474 Fractureofthe
DistalRadius

433 BoutonnièreDeformity

525 UlnarNerveEntrapment
attheWrist

479 FractureoftheMetacarpals
andPhalanges

436 CarpalTunnelSyndrome

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516 TriggerFinger

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SECTION FIVE

Hip and Thigh
528 Paindiagram

558 FractureofthePelvis

586 SnappingHip

530 Anatomy

563 Fractureofthe
ProximalFemur

591 StrainsoftheHip

568 HipImpingement
573 InflammatoryArthritis

604 StressFractureofthe
FemoralNeck

576 LateralFemoralCutaneous
NerveSyndrome

607 TransientOsteoporosis
oftheHip

579 OsteoarthritisoftheHip

609 TrochantericBursitis

582 OsteonecrosisoftheHip

614 Procedure:Trochanteric
BursitisInjection

531 OverviewoftheHip
andThigh
541 PhysicalExaminationofthe
HipandThigh
551 DislocationoftheHip
(Acute,Traumatic)
555 Fractureofthe
FemoralShaft

597 StrainsoftheThigh

SECTION SIX

Knee and Lower Leg
616 Paindiagram

661 Claudication

618 Anatomy

663 CollateralLigamentTear

619 OverviewoftheKnee
andLowerLeg

669 CompartmentSyndrome

632 PhysicalExaminationof
theKneeandLowerLeg

675 FracturesAbouttheKnee

640 AnteriorCruciate
LigamentTear

680 GastrocnemiusTear

647 Procedure:KneeJoint
Aspiration/Injection
650 ArthritisoftheKnee
657 BursitisoftheKnee

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673 Contusions
678 IliotibialBandSyndrome
684 MeniscalTear
689 Osteonecrosisofthe
FemoralCondyle
692 Patellar/Quadriceps
Tendinitis

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697 Patellar/Quadriceps
TendonRuptures
700 PatellofemoralInstability
andMalalignment
704 PatellofemoralPain
711 PlicaSyndrome
716 PoplitealCyst
719 PosteriorCruciate
LigamentTear
724 Shin-Splints
726 StressFracture

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SECTION SEVEN

Foot and Ankle
730 Paindiagram

790 TheDiabeticFoot

832 Metatarsalgia

732 Anatomy

794 Procedure:Careof

DiabeticFeet

834 NailFungusInfection

797 Fracture-Dislocations
oftheMidfoot

839 PlantarFasciitis

733 OverviewoftheFoot
andAnkle
741 PhysicalExaminationof
theFootandAnkle
757 AchillesTendonTear
762 AnkleSprain

800 FracturesoftheAnkle

845 Procedure:Plantar
FasciitisInjection

803 Fracturesofthe
CalcaneusandTalus

847 PlantarWarts

768 ArthritisoftheFoot
andAnkle

806 FractureoftheMetatarsals

771 Procedure:Ankle
JointInjection

811 FractureoftheSesamoid

773 Bunionette

836 OrthoticDevices

809 FracturesofthePhalanges
814 Procedure:Digital
AnestheticBlock(Foot)

849 PosteriorHeelPain
854 PosteriorTibial
TendonDysfunction
858 RheumatoidArthritisof
theFootandAnkle
861 Sesamoiditis

775 Procedure:Application
ofaMetatarsalPad

816 HalluxRigidus

864 ShoeWear

819 HalluxValgus

777 ChronicLateralAnklePain

822 IngrownToenail

868 Soft-TissueMassesof
theFootandAnkle

781 CornsandCalluses

825 Procedure:Nail
PlateAvulsion

870 StressFracturesofthe
FootandAnkle

827 Interdigital
(Morton)Neuroma

873 TarsalTunnelSyndrome

830 Procedure:Interdigital
(Morton)NeuromaInjection

881 TurfToe

784 Procedure:Trimminga
CornorCallus
785 DanceInjuriestothe
FootandAnkle

876 ToeDeformities

SECTION EIGHT

Spine
884 Paindiagram

929 CervicalStrain

957 LumbarSpinalStenosis

886 Anatomy

961 MetastaticDisease

887 OverviewoftheSpine

934 FracturesoftheCervical
Spine

901 PhysicalExaminationofthe
Spine

937 FracturesoftheThoracicor
LumbarSpine

967 SpinalOrthoses

919 CaudaEquinaSyndrome

940 LowBackPain:Acute

970 Spondylolisthesis:
Degenerative

922 CervicalRadiculopathy

946 LowBackPain:Chronic

972 Spondylolisthesis:Isthmic

925 CervicalSpondylosis

952 LumbarHerniatedDisk

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964 ScoliosisinAdults

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SECTION NINE

Pediatric Orthopaedics
976 OverviewofPediatric
Orthopaedics
979 PediatricPhysical
Examination

1056 Diskitis

1131 MetatarsusAdductus

1059 E
valuationofthe
LimpingChild

1135 NeonatalBrachial
PlexusPalsy

1064 Procedure:HipAspiration

1139 Osgood-SchlatterDisease

993 AnteriorKneePain

1066 Flatfoot

997 BackPain

1071 FracturesinChildren

1142 OsteochondralLesions
oftheTalus

1001 ElbowPain

1144 OsteochondritisDissecans

1006 FootandAnklePain

1073 F
racturesofthe
GrowthPlate

1011 GrowingPain

1076 FracturesAbouttheElbow

1013 AccessoryNavicular

1082 FracturesoftheClavicle
andProximalHumerus

1151 PediatricSports
Participation

1015 CalcanealApophysitis
1017 CavusFootDeformity
1021 ChildAbuse
1025 Clubfoot

1029 C
omplexRegionalPain
Syndrome
1032 C
ongenitalDeficienciesof
theLowerExtremity

1085 Fracturesofthe
DistalForearm
1089 FracturesoftheProximal
andMiddleForearm

1147 Osteomyelitis

1155 PreparticipationPhysical
Evaluation
1164 Scoliosis
1170 SepticArthritis

1091 FracturesoftheFemur

1174 Seronegative
Spondyloarthropathies

1094 FracturesoftheTibia

1177 ShoesforChildren

1097 GenuValgum

1180 SlippedCapitalFemoral
Epiphysis

1037 C
ongenitalDeficienciesof
theUpperExtremity

1101 GenuVarum

1040 C
ongenitalDeformitiesof
theLowerExtremity

1112 JuvenileIdiopathic
Arthritis

1046 C
ongenitalDeformitiesof
theUpperExtremity

1118 Kyphosis

1191 ToeWalking

1122 Legg-Calvé-Perthes
Disease

1194 Torticollis

1050 D

evelopmentalDysplasia
oftheHip

1105 IntoeingandOuttoeing

1127 LittleLeagueElbow

1184 Spondylolysis/
Spondylolisthesis
1188 TarsalCoalition

1199 TransientSynovitis
oftheHip

1202 Glossary
1223 Index

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PAIN DIAGRAM

General Orthopaedics

Osteoporosis
Osteoarthritis
Rheumatoid arthritis
Diffuse idiopathic
skeletal hyperostosis
(DISH)

Seronegative
spondyloarthropathies

Rheumatoid arthritis
Complex regional pain
syndrome (CRPS)

Osteoarthritis
Rheumatoid arthritis
Deep vein thrombosis
Complex regional pain
syndrome (CRPS)
Osteoarthritis
Rheumatoid arthritis

Rheumatoid arthritis

Crystal deposition disease

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Crystal deposition
disease

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SECTION 1

General Orthopaedics

25 Anesthesia for
Orthopaedic Surgery

87 Diffuse Idiopathic
Skeletal Hyperostosis

32 Arthritis: Osteoarthritis

89 Drugs: Corticosteroid
Injections

169 Preoperative
Evaluation of Medical

Comorbidities
108 Fracture Evaluation and
Management Principles 175 Rehabilitation and
Therapeutic Modalities
116 Fracture Healing
183 Musculoskeletal
120 Fracture Splinting
Conditioning: Helping
Principles
Patients Prevent Injury
128 Imaging: Principles and
and Stay Fit
Techniques
219 Rehabilitation: Canes,
137 Infection: Osteomyelitis
Crutches, and Walkers
140 Infection: Septic
225 Sports Medicine
Arthritis
Evaluation and
Management Principles
145 Lyme Disease

92 Drugs: NSAIDs

149 Osteoporosis

230 Sprains and Strains

96 Falls and Traumatic

Injuries in the Elderly
Patient

158 Overuse Syndromes

235 Tumors of Bone

xx Pain Diagram
2 Anatomy

52 Arthritis: Seronegative
Spondyloarthropathies

3 Overview of
General Orthopaedics

58 Compartment
Syndrome

8 Principles of
Musculoskeletal
Evaluation

67 Complex Regional Pain
Syndrome

15 Amputations of the
Lower Extremity

39 Complementary and

Alternative Medicine
Therapies for
Osteoarthritis
45 Arthritis: Rheumatoid
Arthritis

73 Crystal Deposition
Diseases
80 Deep Vein Thrombosis

101 Fibromyalgia
Syndrome

165 Pain: Nonorganic
Symptoms and Signs

Section Editor
Letha Y. Griffin, MD, PhD
Team Physician
Georgia State University
Department of Sports Medicine
Peachtree Orthopaedic Clinic
Atlanta, GA

Contributors
Albert J. Alboulafia, MD, MBA
Co-Director of Sarcoma Services
Department of
Orthopaedic Surgery
The Alvin & Lois Lapidus

Cancer Institute
Baltimore, MD

Lindsay Andras, MD
Orthopaedic Resident
Emory Orthopaedics
Emory University
Atlanta, GA
Brian D. Dierckman, MD
Resident
Department of
Orthopaedic Surgery
Emory University
Atlanta, GA
Julie A. Dodds, MD
Associate Clinical Professor
College of Human Medicine
Michigan State University
East Lansing, MI

Joseph M. Lane, MD
Chief
Metabolic Bone Service
Department of Orthopaedics
Hospital for Special Surgery
New York, NY

Michael S. Sridhar, MD
Resident
Department of

Orthopaedic Surgery
Emory University
Atlanta, GA

James S. Kercher, MD
Department of
Orthopaedic Surgery
Emory Univesrity
Atlanta, GA

Thomas J. Moore, MD
Associate Professor
Department of
Orthopaedic Surgery
Emory University
Atlanta, GA

L. Andrew Koman, MD
Chair and Professor
Department of
Orthopaedic Surgery
Wake Forest University
School of Medicine
Winston-Salem, NC

Robert Murphy, MS, ATC
Assistant Athletic Director for
Sports Medicine
Department of
Intercollegiate Athletics

Georgia State University
Atlanta, GA

Harlan M. Starr, MD
Resident Physician
Department of
Orthopaedic Surgery
Emory University School
of Medicine
Atlanta, GA

Lindsey Snyder Knowles, DPT,
STC
Department of Outpatient
Orthopaedics and Sports
Physical Therapy
Atlanta Sport & Spine Physical
Therapy
Atlanta, GA

Michael S. Pinzur, MD
Professor of Orthopaedic Surgery
Department of
Orthopaedic Surgery
Loyola University Health System
Maywood, IL

Michael Huxford, MEd, ATC,
CSCS
Sports Medicine Coordinator

Rehabilitative Services
Institute for Sports Medicine
Children’s Memorial Hospital
Chicago, IL

Jordyn Griffin, BA
Medical Student
Medical College of Georgia
Augusta, GA
George N. Guild III, MD
Orthopaedic Surgeon
Department of
Orthopaedic Surgery
Emory University
Atlanta, GA
Stephen C. Hamilton, MD
Resident
Department of
Orthopaedic Surgery
Emory University
Atlanta, GA
Kyle E. Hammond, MD
Resident Physician
Department of
Orthopedic Surgery
Emory University
Atlanta, GA

E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E

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Brian L. Thomas, MD
Chairman
Department of Anesthesiology
Piedmont Hospital
Atlanta, GA

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1


Anatomy—major bones of the body
Skull

Mandible

Clavicle

Scapula

Humerus

Spinal column

Radius
Pelvis
Ulna

Carpal bones

Metacarpals

Phalanges

Femur

Patella

Fibula

Tibia

Metatarsals
Tarsal bones
Phalanges

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SECTION 1 GENERAL ORTHOPAEDICS

Overview of General
Orthopaedics
Bone, cartilage, muscle, tendon, ligament, and their supporting
nerve and vascular supplies are the specialized structures that
make up the musculoskeletal system. In combination, these
structures provide remarkable strength, movement, durability,
and efficiency. Disease or injury to any of these tissues may
adversely affect function and the ability to perform daily
activities. This General Orthopaedics section of Essentials of
Musculoskeletal Care describes conditions that affect multiple
joints, bones, or regions; conditions that have systemic effects;
and therapeutic modalities commonly used in the nonsurgical
treatment of musculoskeletal conditions. An anatomic drawing
showing the major bones of the human body is on page 2;
detailed anatomic drawing showing the bones and muscles of
the various anatomic areas appear at the beginning of each
anatomic section. A glossary of commonly used orthopaedic
terms is provided on page 1202.

Arthritis
The etiologies of arthritis range from degenerative processes
associated with aging (osteoarthritis) to acute infectious
processes (septic arthritis). Likewise, disability from arthritis
ranges from inconsequential stiffness to severe pain and
crippling dysfunction. Two of the most common forms of adult
arthritis encountered in clinical practice are osteoarthritis and
rheumatoid arthritis (Figure 1). Distinguishing characteristics are

listed in Table 1.
Other types of inflammatory arthritis include the seronegative
spondyloarthropathies, crystal deposition diseases, and septic
arthritis. Of these conditions, septic arthritis is the most urgent,
as it demands immediate diagnosis and efficacious treatment to
prevent joint destruction. Diagnosis typically involves joint fluid
analysis and culture, followed by appropriately tailored
antibiotics, and in most cases, surgical drainage and lavage. The
crystal arthropathies present as acute monoarticular arthritis with
an abrupt onset of intense pain and swelling. The seronegative
spondyloarthropathies are a group of disorders characterized by
oligoarticular peripheral joint arthritis, enthesitis, inflammatory
changes in axial skeletal joints (sacroiliitis and spondylitis),
extra-articular sites of inflammation, association with human
leukocyte antigen B27 (HLA-B27), and negative rheumatoid
factor.
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SECTION 1 GENERAL ORTHOPAEDICS

OVERVIEW OF GENERAL ORTHOPAEDICS

Skull

Clavicle

Mandible

*

Cervical spine
Scapula
Humerus

Spinal column

*

Radius
Ulna

MP joints
PIP joints

Pelvis

*

*

Wrist joint

Lumbar spine

Hip joint

*
*

*

DIP Joints

Femur

*

Patella

Fibula

Knee joint

Tibia

*

MTP joints

Figure 1 Joints commonly affected by arthritis. Blue asterisks indicate joints predominantly affected by

osteoarthritis; red asterisks indicate joints predominantly affected by rheumatoid arthritis. MP =
metacarpophalangeal, PIP = proximal interphalangeal, DIP = distal interphalangeal, MTP =

metatarsophalangeal.

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