Spine Trauma

Spine Trauma – Part A
By:Keith Wilkinson MD FACEP
Keith Wilkinson MD FACEP
St. John Hospital and Medical Center

Spinal Cord Injury
* Background:
o 8,000 -10,000 new cases expected annually
o Young men- mean age 33.5
o More frequently on weekends, holidays, during summer months
* Greater than half of cord injuries occur in the cervical spine region, a third in the thoracic region, and the remainder in the lumbosacral area
* Most cases of spine injury do not involve permanent cord injury
* Majority (90%) caused by blunt
trauma
o Majority from MVCs > falls, gunshot wounds, sports/ recreational activities
Bony Anatomy
Vertebral Anatomy
Anatomy
* Spinal cord occupies:
o ~35% of canal at the level of the Atlas
o ~ 50% of the canal in the lower cervical region (C2-7), thoracolumbar spine
Ventral- front
Dorsal- back
Ascending Spinal Cord Tracks
Dorsal column- medial lemniscus
Ipsilateral loss of tactile discrimination, vibration, joint and muscle proprioception
Leg fibers medial, arms lateral
Crosses just below level of medulla
Dorsal spinocerebellar tract
Transmits unconscious proprioceptive information to cerebellum
Fine coordination of posture
An uncrossed tract
Ipsilateral leg dystaxia
Ventral spinocerebellar tract

Unconscious proprioceptive information to cerebellum
Posture of lower extremities
Crossed tract
Contralateral leg dystaxia
Ascending Spinal Cord Tracks
Lateral spinothalamic tract
Pain and temperature
Crossed tract
Contralateral loss of pain and temperature sensation one segment below lesion
Ventral white commissure
Bilateral loss of pain and temperature
Dorsal Horn
Ipsilateral segmental anesthesia and areflexia
Descending Spinal Cord Tracks
Lateral corticospinal tract
Also called pyramidal system
Volitional motion
90% crossed in medulla
Ipsilateral spastic paresis with pyramidal signs
Ventral corticospinal tract
Mild contralateral muscle weakness
Proximal muscles more affected

Ventral horn
Ipsilateral flaccid paralysis
Dermatome Distribution
Spinal Level Muscle Innervation
Muscle Strength Grading
* 0 Flaccid
* 1 Flicker of muscle contraction
* 2 Full range of motion, gravity excluded
* 3 Full range of motion against gravity only
* 4 Full range of motion against gravity and some external resistance
* 5 Normal

Stability of Spine Fractures
* Three columns-Disruption of 2/3 unstable
A.Anterior column- anterior vertebral body, the anterior annulus fibrosus, anterior longitudinal ligament
B.Middle column-posterior vertebral body wall,posterior annulus fibrosus, posterior longitudinal ligament
C.Posterior column-posterior vertebral arch, posterior ligamentous complex
* Degree of compression
+ Vertebral body compressions > 50 %
generally considered unstable

Spine Fracture Types
* Compression fractures
o Result from axial loading and flexion,
o Failure of the anterior column
o Middle, posterior columns intact
o Usually stable unless > 50% height
o Unlikely to be directly responsible for neurologic damage

Burst Fractures
* Axial load
* Both anterior and middle columns fail
* Retropulsion of bone and disk fragments into the canal
* May cause spinal cord compression

Fracture Dislocations
* Fracture-dislocations
o Most damaging of injuries
o Failure of all three columns
o Compression, flexion, distraction, rotation, or shearing forces

Flexion- distraction
* Seat belt–type injuries
o Particularly where lap belts alone are used
* Failure of both the posterior and middle columns
o Intact anterior column prevents subluxation
* Radiographic findings:
o Increased height of the posterior vertebral body
o Fracture of posterior wall of the vertebral body
o Posterior opening of the disk space.


Clinical Clearance of the Cervical Spine
Cervical spine injury is highly unlikely if the patient has

1) No neck pain or tenderness
2) No neurologic signs or symptoms
3) No loss of consciousness
4) Normal mental status
5) No distracting injury

Cervical spine series
* Sensitivities for a cross table lateral demonstrating all 7 cervical vertebra vary (77- 90%)
* Sensitivity of full three view series (lateral, AP and odontoid views) increases to 80% to 100%
o Odontoid 10%, AP 1%
* If cervical fracture found:
o 50% have fx at adjacent level
o 15% have fx in another part of cervical spine
o 10% have fx in thoracic/lumbar spine

Interpreting Cervical Spine X-rays
* True lateral identifies 80- 90% of significant bony or ligamentous lesions
o Adequate films
+ Full visualization of all seven vertebrae
+ C7-T1 injuries are not common, seen with swimmer's view
* Open-mouth odontoid view identifies most of the remaining 10% of significant lesions
o Look for normal alignment and equal spacing between C2 and the lateral masses of C1
* AP or oblique views rarely identifies injury not already suspected

Cervical Spine Radiographs
* Most missed fractures due to inadequate films of the cervico-cranium, C7- T1 junction
* Cervical CT should be used to assess C1-C2 in victims of severe head trauma (GCS < 10, intracranial hemorrhage, skull fractures), when unable to obtain an open mouth or anteroposterior odontoid view
* The open mouth odontoid view is unreliable in unconscious intubated patients missing nearly 16% of injuries
* Up to 15% of cervical spine injuries are missed when the lateral view alone is used to clear patients
* Addition of CT increases sensitivity to 95-100%

Cervical Spine Radiology and the Unconscious Patient

Cervical Spine Radiology
Dens view
Fuchs view
Cervical Spine Radiology
Swimmer’s View
Cervical Spine Radiology
* Look for
o Normal atlanto-occipital alignment
o Predental space 3 mm or less
o Prevertebral soft tissue space less than 5 mm anterior to C3
o Spinal canal plain film anteroposterior diameter 13 mm or greater
o Any horizontal translation of one vertebra on the next
o Fanning of the space between spinous processes
o Fracture of any bone

3 Rules of 3
* The predentate space should be < 3mm
* The prevertebral soft tissue at C3 is usually 3 mm
* Anterior wedging of 3mm or more suggests a fx
Flexion/ extension views
o Used carefully to demonstrate spinal column stability if the initial three views raise a question but would predict a stable spinal column
+ Small chip fracture of the anterior-inferior margin of the vertebral body
+ 1 to 2 mm with no other noted abnormalities
o Used when the initial three views are normal but the pain seems out of proportion, suggesting greater occult ligamentous damage
o Requires awake, cooperative patient
o Abnormal if there is more than a 3.7-mm step-off of one vertebra on the next or if there is an 11° or greater angulation between vertebral segments
* Flexion-extension views
o No urgency
o Fluoroscopic examination of the unconscious patients has a specificity of about 99% and a sensitivity of 92%
o 625 patients with two suffering neurological deterioration, one with complete quadriplegia

Spine Imaging
* CT/ MRI
o The incidence of unstable spinal injury in the unconscious intubated patient is about 10%
o MRI not as sensitive as CT for imaging bone injuries
o MRI- Superb at defining neurologic, muscular, and soft tissue injury
+ MRI may also be used to identify ligamentous injury
+ Indicated in all patients with neurologic symptoms or physical findings but no clear explanation on plain films and/or CT
CT
* Excellent for upper spine anatomy, rotational injuries, degenerative vs. acute subluxations, subtle compressions
o High incidence of upper cord injury with ICH, GCS < 8
* 3-d reconstructions add improved detail

MRI
Unstable Cervical Spine Fractures
* Jefferson fracture
* Hangman’s fracture
* Teardrop fracture
* Bilateral locked facets

C spine Mechanism of Injury
HYPERFLEXION INJURY (46-79%)
* odontoid fracture
* simple wedge fracture (stable)
* tear drop fracture
* anterior subluxation
* bilateral locked facets (unstable)
* anterior disc space narrowing
* widened interspinous distance
* clay shoveler’s fracture
HYPEREXTENSION INJURY (20-38%)
* anteriorly widened disc space
* prevertebral swelling
* tear drop fracture
* neural arch fracture of C1
* subluxation (anterior/posterior)
* hangman’s fracture
Unstable Cervical Spine Fractures
* FLEXION:
o bilateral interfacetal dislocation
o flexion teardrop fracture (usually C5 or C6)
* EXTENSION:
o extension teardrop (usually C2 or C3)
o hangman’s fracture
o extension-dislocation
o extension-fracture-dislocation
o odontoid fracture
* VERTICAL COMPRESSION:
o Jefferson burst fracture

Spine Trauma – Part A
Spine Trauma – Part B

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Common Foot & Ankle Problems

Common Foot & Ankle Problems

Hallux Valgus / Bunion Deformity
* A structural (bony) deformity where the metatarsal bones spread apart causing a prominent bone to protrude on the inside of the foot.
* A progressive deformity.
* May be treated conservatively, but usually requires surgical correction if pain persists.

Bunion prior to correction
Bunion after correction
Severe Hallux Valgus / Bunion Deformity
Cut in bone and fixation with screws

Tailor’s Bunion / Bunionette
* Bony deformity which is located on the outside part of the foot.
* The bump, bunionette or Tailor’s Bunion, can become very painful due to shoe irritation.
* Tailor’s bunions may be treated conservatively. Surgical correction may be necessary.

Note prominent 5th metatarsal head with swelling
Note Bowing of the Metatarsal
Note Straight Metatarsal
After Correction
Prior to Correction
Tailor’s Bunion / Bunionette
Hammertoe Deformity
* Contracted or abnormal position of the toes, which may be flexible or rigid in nature.
* Usually caused by weakened muscles of the foot.
* May cause pain due to irritation from other toes. The pain may be exasperated by tight fitting shoes.
* Hammertoes are often accompanied by a corn or callous.
Toe prior to surgery
Toe after surgery
Hammertoe Deformity
Hallux Rigidus
* Osteoarthritis of the big toe joint usually associated with pain and restricted motion.
* May be caused by injury or repetitive joint damage due to a biomechanical / structural problem of the foot.
* Chronic wear and tear causes a wearing out of the cartilage at the joint and bone spurs to form.
Hallux Rigidus of the Big Toe Joint
Note bone spur formation

Hallux Rigidus of the Big Toe Joint
Note joint space narrowing and bone spur formation at the joint margins
Rheumatoid Arthritis
* An inherited arthritis which affects joints in the feet and hands.
* The joint destruction and deformities are progressive in nature.
* May predispose patients to bunion and hammertoe formation.
Bunion Deformity
Hammertoe Deformities
Rheumatoid Arthritis
Rheumatoid nodule
Plantar Wart
* Human papaloma virus infection in the feet.
* Warts are obtained by barefoot exposure to the virus.
* Warts are often spread in showers, gyms, or other areas where barefoot walking is common.
* May be treated with any number of methods but recurrence ranges between 18-22%.
Plantar Wart
Callous / Corn
* Thickened area of skin caused by chronic rubbing or irritation of a bony prominence by the ground or shoe gear.
* Very high areas of pressure within a callous can develop a painful central core.
* Lesions reoccur because the cause of the lesion is often from bone.
Callous / Corn
Athletes Foot
* A fungal infection typically caused by fungus found in soil (Dermatophyte).
* Picked up by contact with the fungus usually walking barefoot (Gym, hotel, pool, etc.).
* May occur anywhere on the foot and may burn and/or itch.
* The affected areas of skin will often peel or may have small blisters.
Ingrown Nails
* Toenail which grows into the skin. Most often caused by a wide toenail and an external pressure.
* The nail may cause pain or infection due the pressure of the nail border.
* May be treated with removal and/or antibiotics. May be permanently corrected with retaining a normal nail appearance.
Fungal Toenail
* A thickened nail caused by a fungus.
* Initially caused by an injury to the nail which allows the organism to enter the nail.
* Progressive in nature and slow growing.
* May spread to other nails or other people in close contact. Organism may also spread from nail to the skin (athletes foot).
* May be treated if pain or concerns arise.
Fungal Toenail
Fungal Infection which caused ingrown nail
Thickened curled nails caused by fungus
Nail Injury
* Chronic injury (i.e. athletic activities) causes injury to the nail root and results in nail horizontal layers.
* Isolated injury may also cause bleeding under the nail, leaving a dark spot which persists until the nail grows out.
Lines of injury
Dried blood under the nail plate from injury.
Eczema
Gout
Redness and swelling of the big toe joint
High Arched Feet / Pes Cavus
Pes Cavus / High Arch Feet
Flat Feet
Note low medial arch height
Pes Planus / Flat Feet
Note collapse of entire foot inward
Note low medial arch height
Plantar Fascitis / Heel Spur Syndrome
* Inflammation and partial tearing of a ligament band which attaches from the heel to the ball of the foot.
* Usually a result of poor arch support and overuse.
* May be accompanied by a calcified spur on the heel.
* Usually resolves with conservative treatments.
Ankle Sprain
* Tear or stretching of the ligaments of the ankle. Usually the ligaments on the outside of the ankle are involved.
* Caused by and twisting injury of the foot / ankle .
* Instability of the ankle can develop due to the ligament injury.
* Most often treated conservatively. Surgical repair can be performed to treat chronic ankle sprains.
Bruising after ankle sprain
Morton’s Neuroma
* Injured or compressed nerve most often between the 3rd and 4th toes.
* Burning / pain on the ball of the foot or toes.
* Patients may feel fullness or a mass in the area when they walk.
* Treatments may be conservative or surgical.
Haglund’s Deformity / Retrocalcaneal Exostosis
* Prominent bone on the back of the heel.
* Back of the heel is irritated by shoes and activity, which places pressure on the area.
* Can also be aggravated by a tight Achilles tendon over prominent heel bone.
* Treatments may be conservative or surgical.
Ulcerations
* Erosions of the skin caused by loss of sensation or poor circulation.
* Skin break down occurs which, places patients at risk for local or systemic infection.
Ischemic Ulceration(Ulcer due to poor circulation)
Diabetic Ulceration
Ganglion Cyst
* Benign soft tissue mass which arises from a weak area in a tendon lining or joint.
* Cyst is often filled with a gelatinous fluid.
* Cyst may change size depending on irritation.
Subungual Exostosis
* Bone and cartilage growth under the great toe nail.
* Pain may arise if pressure is placed over the area.
* May be treated with shoe style changes, nail removal or surgical removal.
Venous Stasis
* Discoloration of skin due to longstanding swelling of legs.
* Persistent swelling can lead to skin breakdown.
* Compression and elevation of the legs are essential to the prevention of complications.
Heel Fissuring / Cracking
Heel Fissuring with Hyperkeratosis
Fractured Proximal Phalanx (Toe)
Fractures
Hyperhydrosis
Achilles Tendonitis
Inflammation of tendon

Common Foot & Ankle Problems.ppt

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Joints of the Foot

Joints of the Foot

There are 26 bones in the foot; all but five are involved in at least two joints.
* Hind foot
* Midfoot
* Forefoot
* foot biomechanics1

Subtalar joint: where the talus rests on and articulates with the calcaneus. This is a synovial joint with a weak capsule supported by medial, lateral, posterior & interosseous talocalcaneal ligaments.

* The interosseous talocalcaneal ligament (very strong) lies in the tarsal sinus (separates the anterior & posterior talocalcaneal joints).
* Anatomical subtalar joint- functionally a single synovial joint between the slightly concave articular surface of the talus and the convex posterior articular surface of the calcaneus.

Important Intertarsal joints:
1. Subtalar (talocalcaneal) joint
2. Transverse tarsal joint (calcaneocuboid & talonavicular)

* The main movement at these joints are foot eversion & inversion, eversion is augmented by extension of the toes (especially the lateral toes), inversion is augmented by toe flexion especially the 1st &2nd toes.

Transverse tarsal joints – a compound joint
1. Talonavicular part of the talocalcanealnavicular joint

2. Calcaneocuboid joint

* These 2 separate joints are aligned transversely. At this joint the forefoot & midfoot rotate as a unit on the hind foot around an AP axis. This augments inversion/eversion of the foot.
* Anatomical amputations of the foot are made through this joint.


1. Intertarsal joints:
These bones are so tightly opposed by ligaments that little movement occurs between them

2. Tarsometatarsal joints:
Plane type synovial joints involved in gliding/sliding type movements

3. Metatarsophalangeal joints
Flexion/extension in the foot occurs at the metatarsalphalangeal joints & the interphalangeal joints

4. Interphalangeal joints
Each has plantar, medial & lateral collateral ligaments, dorsal extensor aponeuroses act as dorsal ligaments.

All the joints proximal to the metatarsalphalangeal joints are united by dorsal & plantar ligaments.

All the bones of the metatarsals and interphalangeal joints are united by lateral & medial collateral ligaments.

Major ligaments of the Plantar foot
Plantar calcaneonavicular (Spring) ligament

* Fills a wedge shaped gap between the talar shelf & inferior margin of the posterior articular surface of the navicular. This ligament supports the head of the talus and plays an important role in the transfer of weight from the talus & maintaining the longitudinal arch.

Long Plantar Ligament
* Traverses from the plantar surface of the calcaneus to the groove on the cuboid. Some fibers extend to the base of the metatarsals (forming a tunnel for the tendon of the fibularis longus. This ligament is important in maintaining the longitudinal arch.

Plantar calcaneocuboid (short plantar) ligament:
* Located deep to the long plantar ligament, it runs from the anterior part of the inferior surface calcaneus to the inferior surface of the cuboid. It is located on a plane between the plantar calcaneonavicular (spring) ligament and the long plantar ligament. It is also involved in maintenance of the longitudinal arch.

Arches of the Foot
* The ligamentous bony arrangement of the foot allows considerable flexibility/deformation with weight bearing contact. The arches distribute the weight of the foot (pedal platform) acting both as shock absorbers & spring boards during ambulation of all types.
* Weight distribution is between the calcaneus and sesamoid bones at the 1st metatarsal and head of the 2nd metatarsal; weight is shared laterally with the heads of metatarsals 3-5. Elastic arches between weight bearing points compress with loading and recoil with unloading.
* Lateral Longitudinal arch
* Medial Longitudinal arch
* Transverse Arch

All three work as a unit in weight bearing

* Medial Longitudinal Arch higher and more prominent than the lateral arch.
* Consists of the calcaneus, talus, navicular, 3 cuneiforms and 3 metatarsals
* Talar head is the keystone of the medial longitudinal arch
* The medial arch is supported by the Tibialis anterior ligament as it attaches to the 1st metatarsal and medial cuneiform. Also the tib posterior & FHL.
* The tendon of the fibularis longus passes from lateral to medial and also supports the medial longitudinal arch.
* Lateral Longitudinal Arch is much flatter and consists of the calcaneus, cuboid & lateral metatarsals.
* The medial arch is involved in weight bearing while the lateral arch is involved in balance
* Transverse arch: cuboid, cuneiforms and bases of the metatarsals. This forms the medial & lateral parts of the longitudinal arches which serve as pillars fro the transverse arch.
* The tendon of the fibularis longus & tibialis posterior crossing the sole of the foot obliquely help maintain the curve of the transverse arch.
* The Arches of the foot are maintained by both passive & dynamic supports.

Passive factors
1. Shape of the united bones (especially the transverse arch).

2. 4 layers of fibrous tissue
o 1. Plantar aponeurosis
o 2. Long plantar ligament
o 3. Short plantar ligament
o 4. Spring ligament

Dynamic Support
1. Active (reflexive) bracing action of the intrinsic muscles of the foot support the longitudinal arches.
2. Active & tonic contraction of muscles & tendons extending into the foot:
Longitudinal arch
flexor hallicus longus
flexor digitorum longus
Transverse arch
fibularis longus
tibialis posterior &anterior
3. Plantar ligaments & aponeurosis bear the greatest stress and are most important in maintaining the arches.

Pes Planis (flat feet)
Prior to 3 years of age it is normal to have flat feet due to a fat pad. After the age of 3 this fat pad disappears.

Pes planis can be classified as:

* Flexible: the arch is normal when unloaded however with loading the arch is lost. this is the most common type. It is due to inadequate passive arch support (weak, loose ligaments).
* Rigid type, the arch is absent regardless of loading, this may be due to a congenital deformity.

* Acquired “fallen arches” is due to a tibialis posterior dysfunction due to trauma, denervation and/or degeneration. The plantar calcaneal ligament fails allowing the head of the talus to rotate inferomedially creating a prominence on the medial aspect of the mid-hind foot junction. This is often referred to as over pronation.

Talipes equinovarus (Club foot)
* Club Foot
* A congenital deformity males/females 2/1 Foot inverted, ankle plantarflexed and forefoot abducted. The abnormality is related to short, tight muscles, tendons and ligaments.

* Orthopedic Subtalar joint: anatomical subtalar joint + talocalcaneal part of the talocalcaneonavicular joint (these straddle the interosseous talocalcaneal ligament
* The main movement at this subtalar joint is inversion/eversion.

Joints of the Foot.ppt

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Mechanism of Bone Metastases

Mechanism of Bone Metastases
by: Dr.Priya Gopalan

Outline
* Background
* Predictors of metastasis to bone
* Tumor cell homing to bone
* Tumor cell interaction with bone
* Therapeutic interventions

Bone Metastases
Types of bone metastases
Diagnosis
* Bone scan - best for osteoblastic lesions
* MRI
* CT scan with bone windows
* PET-CT
* Plain films
* Markers of bone turnover

Prognosis
Relative risk ratios during zoledronic acid therapy
(skeletal-related events)
NSCLC and solid tumors
High vs. low NTX levels
Reasons for preferential metastasis to bone
* Highly vascular organ (sluggish blood flow)
* Paget’s “seed-and-soil” hypothesis
o Bone marrow niche provides:
+ Chemotactic signal to home (e.g. SDF-1)
+ Adhesion receptors to extravasate
+ Growth factors to proliferate (e.g. TGF-b, IGF-1)
Predictors of metastasis to bone (Breast Cancer)
Tumor cell homing
* Organs that are primary sites of breast cancer metastasis produce high levels of SDF-1
* Blocking CXCR4 in vitro inhibited prostate cancer migration through bone marrow endothelial cells
* Blocking CXCR4 in vivo reduces bone metastases in breast and prostate cancers
* CXCR4/ SDF-1 axis also important in
o NSCLC:
o RCC:
* Integrins may also direct organ-specific mets
o When avb3 is overexpressed on breast cancer cells, bone metastases are enhanced
o CXCR4 binding to SDF-1 activates avb3 and mediates its binding to endothelial cells
o avb3 antagonist inhibits bone colonization by avb3-expressing tumor cells
o a2b1 on prostate cancer cells supports bone colonization
* Other chemokines produced by OBs
o Osteopontin
o Bone sialoprotein

Normal bone remodeling
Osteoprotegerin
Osteoblasts/osteoclasts interaction with tumor cells
Osteomimicry by tumor cells
Therapeutic targets
* Osteoblastic lesions
o Endothelin-1 (anti-receptor antibody)
* Osteolytic lesions
o Bisphosphonates
o RANKL (anti-RANKL antibody)
o PTHrP
o Osteoprotegerin (Fc-OPG)
* Endothelin A receptor inhibitor, Atrasentan
o M00-211 trial - Double-blinded, randomized, multi-institutional placebo-controlled Phase III trial with 809 patients with hormone-resistant metastatic prostate cancer

+ Endpoint - TTP
+ Results
# TTP HR 0.89 (CI 0.76,1.04, p=0.136)
# Median time to bone alk phos progression 505 vs 254 days (p<0.01)

Bisphosphonates
* Long-term treatment of osteolytic metastases
* Preferentially bind areas of high bone turnover
* Aminobisphosphonates
o e.g. zoledronate, aledronate, risedronate
o Block prenylation of osteoclast proteins (small GTP-binding proteins, e.g. ras and rho), leading to apoptosis
* Non-aminobisphosphonates
o e.g. clodronate, etidronate
o Inhibit ATP-dependent enzymes, leading to apoptosis
* Also may inhibit tumor adherence to bone, inhibit angiogenesis, reduce IL-6 production

Bisphosphonates-clodronate
* Clodronate approved in Europe but not US
* Double-blind, placebo-controlled, multicenter trial with 1,069 patients with operable breast cancer randomized to clodronate or placebo
o 1° endpoint - relapse in bone
o 2° endpoints - relapse in other sites, mortality, toxicity
o Significant reduction in bone metastases during medication period (HR 0.44, CI 0.22-0.86, p=0.016), but not in total follow-up period
o Reduced mortality (98 in clodronate arm, 129 in placebo arm, p=0.047)

Bisphosphonates-pamidronate
* 754 pts with metastatic breast cancer (with osteolytic bone metastases) randomized to pamidronate or placebo
o 1° objective - skeletal events per year and time to 1st skeletal-related event (SRE)
o Only 115 of 367 (31.3%) on pamindronate arm and 100 of 384 (26.0%) on placebo arm completed the study
o Pamidronate arm - 2.4 skeletal events/yr; placebo arm - 3.7 events/yr (p<0.001); also observed longer time to 1st SRE in pamidronate arm (12.7 vs 7 months, p<0.001)
o Limited by significant number of pts who did not complete study
Bisphosphonate - zoledronate

* 1803 premenopausal women with Stage I and II breast cancer randomized to tamoxifen/anastrozole ± zoledronic acid
* 1° endpoint DFS; 2° RFS, OS; explor: bone met-free survival
* DFS (HR 0.643 [CI 0.46-0.91], p=0.011)
* RFS (HR 0.653 [CI 0.46-0.92], p=0.014)
* No change in OS
* See effects outside bone

Bisphosphonates - zoledronate (prostate cancer)
* Zometa 039 trial: 643 men with hormone-refractory metastatic prostate cancer received zoledronate 4 mg, 8mg then 4mg, or placebo for 18 months
o Zometa decreased SREs and pain, but no difference in disease progression or performance status
* Trials with pamidronate and clodronate in metastatic prostate cancer showed no significant benefits
* Randomized, placebo-controlled Phase III trial, with 773 pts with lung, RCC, etc. metastatic to bone randomized to zoledronate vs placebo q3 months for 21 months
* 1° endpoint - % patients with ≥1 SRE
* Zolendronate delayed the onset and reduced risk of skeletal-related events compared to placebo in pts with bone metastases due to lung cancer or other solid tumors.
o Reduced time to 1st SRE with treatment (236 vx 155 days, p=0.009), decreased number of events/year (1.74 vs. 2.71, p=0.012), HR developing skeletal event reduced in zoledronate arm (HR 0.693, p=0.003)

Bisphosphonates
* Osteonecrosis of the jaw

Other therapies

Mechanism of Bone Metastases.ppt

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Foot and Ankle Complaints

Foot and Ankle Complaints
By:Allyson Howe, MD
Major USAF MC
Capital Conference 2007


INTRODUCTION
* Anatomy and Function
o Foot
o Ankle
* Common complaints
* Common diagnoses

FOOT AND ANKLE ANATOMY
* 26 bones and 2 sesamoids
* Forefoot
o Metatarsals
o phalanges
* Midfoot
o 5 tarsals
* Rearfoot
o Talus and Calcaneus

FOOT AND ANKLE
* FUNCTIONS
o Absorb impact loading forces
o Adapt to uneven ground
o Allow efficient propulsion
FOOT AND ANKLE COMPLAINTS
HISTORICAL CLUES
* Previous injury?
* New shoes?
* New sport/activity?
* Sudden increase in mileage?
* Long term training without rest?
FOOT AND ANKLE COMMON COMPLAINTS
* Heel pain
* Forefoot pain
* Ankle pain
* Numbness/tingling/burning
* Ankle swelling
* Heel pain
* Forefoot pain
* Ankle pain
* Numbness/tingling/burning
* Ankle swelling

HEEL PAIN
* Determine location
o Plantar surface
+ Plantar fasciitis
+ Heel pad atrophy
+ Distal tarsal tunnel syndrome
+ Calcaneal stress fracture
o Posterior heel
+ Retrocalcaneal bursitis
+ Achilles tendinopathy
+ Sever’s disease
+ Stress fracture
+ Lateral Plantar Nerve entrapment

Consider inflammatory conditions also:
Gout
Reiter’s
Psoriasis

PLANTAR FASCIITIS
* Pain at the most anterior portion of the heel pad
* Medial tubercle
* Worst with first step in the morning or after inactivity
* Pain increases with active dorsiflexion of first toe
* Treatment
o ICE
o Stretching
o NSAIDs
o Correction of arch abnormalities
o Improved shoe quality
o Training adjustment
o Night splints
o Injections

HEEL PAD ATROPHY
TARSAL TUNNEL SYNDROME
RETROCALCANEAL BURSITIS
ACHILLES TENDINOPATHY
SEVER’S DISEASE aka. Calcaneal Apophysitis
LATERAL PLANTAR NERVE ENTRAPMENT
FOREFOOT PAIN
* Acute
* Trauma
* Chronic
5th METATARSAL FRACTURE
METATARSAL FRACTURE
GOUT
LIS FRANC SPRAIN
METATARSALGIA
STRESS FRACTURE
ANKLE PAIN
OSTEOCHONDRAL DEFECT
ANKLE SPRAIN
OTTAWA ANKLE AND FOOT RULES
Ottawa Ankle Rules
Radiographs
A-P View of Ankle
Lateral View of Ankle
Mortise View of Ankle
Mortise View Normals
CLASSIFICATION OF LATERAL ANKLE SPRAINS
Instability testing
Grade II
Grade I
OTHER (THAN LATERAL) ANKLE SPRAINS
ANKLE SPRAIN TREATMENT
NON-HEALING ANKLE SPRAINS
NUMBNESS/TINGLING/BURNING
Peripheral Neuropathy
Diabetes
Nutritional deficiency
Alcoholism
Heavy metal exposure
Chemotherapy
Renal disease
INH therapy
HIV
JOGGER’S FOOT
MORTON’S NEUROMA
ATRAUMATIC ANKLE SWELLING
TAKE HOME POINTS
RHEUMATOID ARTHRITIS
* ANKLE
o Ankle sprains- medial and lateral and high
+ Ottawa ankle rules
o Achilles tendonitis
o Retrocalcaneal bursitis
o Posterior tibial tendonitis
o Sever’s disease (calcaneal apophysitis)
o Tarsal tunnel syndrome
o OCD
* FOOT
o Plantar fasciitis
o Metatarsalgia
o Morton’s neuroma
o Tarsal tunnel
o Toe fracture
o Navicular stress fracture
o Freiberg’s infarction

Foot and Ankle Complaints.ppt

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Osteoporosis

Osteoporosis
Capital Conference 2007
By:Marc Childress, MD

Osteoporosis
* Epidemiology
* Risk Factors
* Prevention
* Screening
* Diagnosis
* Treatment
* Osteoporosis in Men
* Management
* Falls
* Acute Complications

Osteoporosis
* Average female bone mineral density peaks at age 35, slow decline thereafter
* Density loss is accelerated post-menopausally

Epidemiology
Risk Factors
Predisposing Medical Conditions
* Estrogen Deficiency
* Inflammatory Bowel Disease
* Type 2 Diabetes Mellitus
* Celiac disease
* Cystic fibrosis
* Hyperthyroidism
* Hyperparathyroidism
* Hypogonadism
* Liver Disease
* Corticosteroid use
* Heparin use
* Cyclosporine use
* Depo-Provera use
* Vitamin A (systemic retinoid) use
* No clear increase in risk with carbonated beverages
* Chronic excess thyroid hormone replacement
* diffuse nontoxic goiter
* osteoarthritis
* osteoporosis
* hyperparathyroidism
* Addison’s disease
* Hypothyroidism
* Osteogenesis imperfecta
* Anticonvulsive medication

Prevention
* Adequate total dietary calcium
* Vitamin D
* Regular weight-bearing exercise
* Additional protective factors: increased BMI, African-American ethnicity, moderate EtOH intake
* Which of the following antihypertensives agents may help preserve bone mineral density?
* Atenolol (Tenormin)
* Doxazosin (Cardura)
* Enalapril (Vasotec)
* Hydrochlorothiazide
* Nifedipine (Procardia, Adalat)
* Which one of the following is associated with a reduced risk of post-menopausal osteoporosis?
* Corticosteroid use
* Cigarette smoking
* Diuretic use
* Low BMI
* Asian Ethnicity
Screening
* USPTF/AAFP— “routine screening” above the age of 65, consider between 60-65 for increased risk
* National Osteoporosis Foundation—recommend screening above 65, or in younger with risk factors
* Difficulty with recommendations
Screening Options
* Single Photon absorptiometry
* Dual Photon absorptiometry
* Dual X-ray absorptiometry (DEXA)—MOST POPULAR
* Quantitative CT
* Ultrasound

Diagnosis
Treatment
* Raloxifene (Evista)
* is used to manage hot flashes
* increases bone density
* stimulates breast tissue
* stimulates endometrial proliferation
* raises LDL and total cholesterol levels

Osteoporosis in Men
Chronic Management
Falls
Acute Complications

Osteoporosis.ppt

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Joints Presentations

The Elbow and Radioulnar Joints

Joints

Articulations

Upper Extremity Joints

Joints

Joints - Articulations

The Wrist and Hand Joints


Dem Bones

Arm, Elbow, Forearm

Upper Extremity Injuries

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Elbow, Wrist & Hand presentations

Elbow, Wrist & Hand Evaluation

The Shoulder Girdle
R.T. Floyd, EdD, ATC, CSCS

Muscular Analysis of Upper Extremity Exercises

The Shoulder Joint

Muscular Analysis of Trunk and Lower Extremity Exercises

Foundations of Structural Kinesiology

Source:Eastern Illinois University

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Spine presentations

Spine Biomechanics, Intervertebral Disc &LBP

Assessment of the cervical spine

The Cervical Spine

Anesthesia For Pediatric Spinal Surgery
by:Dr Deborah Elkon

Lifting and Your Back

Flouro Images of Lumbar Spine Injections
David F. Drake, MD

Common Spine and Spinal Cord Syndromes
by:Gabriel C. Tender

Thoracic Spine
by:Dr. Michael Ramcharan

A (Linear) Spine Calculus
by:Iliano Cervesato

Spine Trauma
by:Keith Wilkinson

Minimally Invasive Spine Surgery (MISS)
Post Operative Care by:H. Dennis Mollman

Head and Spine Injuries

Spine and Thorax

Injuries to the Head and Spine

Quiz on Shoulder and Spine
By Robert Pankey, Texas State University

Posterior Oblique Lumbar Spine

Spine Special Tests

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Cervical Rib Resection Procedure

Cervical Rib Resection Procedure
Presentation by:April Carter RN,MSN,CNOR
NorthWest Florida State College

Objectives

* Assess the related terminology and pathophysiology of the lungs.
* Analyze the diagnostic interventions for a patient undergoing a cervical rib resection
* Plan the intraoperative course for a patient undergoing
* Assemble supplies, equipment, and instrumentation needed for the procedure.
* Choose the appropriate patient position
* Identify the incision used for the procedure
* Analyze the procedural steps for cervical rib resection.
* Describe the care of the specimen

Terms and Definitions
* Thoracic outlet: formed by the first ribs, spine, and sternum
Definition/Purpose of Procedure

* Decompression of the thoracic outlet through partial or entire removal of the rib
* Surgical Goal: release compression of the neurovascular tissue and restore neurovascular function to the affected upper extremity, neck, or shoulder

Pathophysiology
* Thoracic Outlet Syndrome
o Compression of the subclavian vessels and the brachial plexus at the apex of the thorax.
o Other names: cervical rib syndrome, first thoracic rib syndrome, costoclavicular syndrome, hyperabduction syndrome
o Classifications
+ Arterial thoracic (result compression of subclavian artery and results in severe ischemia of arm)
+ Neurological
+ Venous thoracic

Surgical Intervention:
Special Considerations
Surgical Intervention: Positioning
* Position during procedure
Surgical Intervention: Special Considerations/Incision
Surgical Intervention: Supplies
Surgical Intervention: Instruments
Thoracic Instrumentation
Surgical Intervention: Equipment
Surgical Intervention: Procedure Steps
Surgical Intervention:
Procedure Steps
Specimen & Care
Resources
For visualization of the pleurae, lower and middle mediastinum, and pericardium, the surgeon would need a:

* Thorascope
* Mediastinoscope
* Bronchoscope
* Laryngoscope
As the STSR, with which of the following procedures would you anticipate the use of chest tubes and a water-seal drainage system?
* Lobectomy
* Scalene Node Biopsy
* Percutaneous Transluminal Coronary Angioplasty
* Cardiac Pacemaker Insertion

Which of the following retractors would be most useful in a posteriolateral Thoracotomy?
* Balfour
* O’Sullivan-O’Connor
* Davidson scapula
* Weitlaner

With which of the following procedures would you expect the greatest amount of bleeding?
* Wedge Resection of the Lung
* Decortication of the Lung
* Open Thoracotomy fro Closure of a Ruptured Bulla
* Closure of a Patent Ductus Arteriosus

The removal of a lung is referred to as a/an:
* Pneumonectomy
* Endarterectomy
* Blalock-Hanlon operation
* Cryoablation

Cervical Rib Resection is performed to relieve:
* Thoracic Inlet Syndrome
* Thoracic Outlet Syndrome
* Adult Respiratory Distress Syndrome
* pneumothorax

The procedure performed to remove a fibrous covering from the lung following empyema formation is:
* Aneurysmectomy
* Thoracostomy
* Thymectomy
* Pulmonary Decortication

When two chest tubes are placed into the pleural space, the uppermost tube is used to:
* Evacuate air/re-establish negative pressure
* Evaluate blood/re-establish positive pressure
* Evacuate serous fluid/re-establish positive pressure
* Evacuate pus/re-establish negative pressure

When a rib is removed, the remaining bone edges are trimmed with a:
* Doyen raspatory
* Bethune shear
* Lebsche knife
* Stille-Luer rongeur

When transporting a patient with a closed water-seal drainage:
* The bottle should be kept at or above the height of the patient’s chest
* The chest tube should always be clamped
* Chest tube clamps should accompany the patient at all times
* The patient should be placed in Trendelenburg position

Mediastinoscopy is usually performed with the patient in what position?
* Lateral
* Sims
* Dorsal recumbent
* prone

Removal of air or fluid from the pleural cavity via needle aspiration is:
* Thoracoscopy
* Thoracotomy
* Hemocentesis
* Thoracentesis

Cervical Rib Resection Procedure.ppt

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Common Problems in Geriatrics for Orthopedic Surgeons

Common Problems in Geriatrics for Orthopedic Surgeons
Presentation by
Steven Zweig, MD

Family and Community Medicine
MU School of Medicine

Goals

* Recognize the importance of aging physiology in the development and treatment of specific problems
* Prevent and treat delirium
* Recognize the significance of polypharmacy
* Identify patients at risk for elder abuse

Case 1 - 80 year old woman with hip fracture
Delirium
* Physical exam for VS, neuro, skin, infections
* Mental status exam
* Lab and x-ray for infections (lung, urine), fluid and lytes, hypoxia, BS, new trauma, systemic dx

Mental Status Evaluation

Case 2 - 76 year old woman with osteoarthritis
Altered Drug Distribution
Altered Drug Metabolism
Altered Renal Excretion
Common Adverse Drug Reactions
Principles of Geriatric Prescribing


Case 3- 75 year old woman with upper arm pain

X- ray and lab findings
Elder Abuse
Risk factors
Management

Tips for Coordinating Care

* Medicare home care - requires need for skilled nurse or PT
* Admission to SNF requires 3 day hospital stay - contact the NH physician to plan
* PPS means capitated reimbursement to SNFs
* Medicare does not cover costs of drugs
* Get SW involved if any care problems anticipated

Common Problems in Geriatrics for Orthopedic Surgeons.ppt

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