Causation

Pattern (→ Fig. 17.1)

Figure 17.1 Types of fracture.

Relation to surrounding structures

First aid

Follow Advanced Trauma Life Support (ATLS) principles (→ Ch. 4). Ensure clear airway. Ensure adequate breathing. Stop bleeding. Splintage to prevent further damage by movement of fragments. If open fracture, cover with Betadine-soaked gauze, administer prophylactic antibiotics and check tetanus status.

Treatment of shock

Considerable blood loss can occur with fractures – 1.5 L can be lost with a femoral shaft fracture. Multiple fractures can lead to considerable blood loss. Ensure adequate treatment of shock with blood or plasma expanders before investigation and treatment.

The fracture itself

Methods of stabilizing a fracture

External

Plaster of Paris (or synthetic materials)

This may be used for splints, casts or jointed casts. It is usually applied over a layer of wool. Where there is excessive swelling, a slab may be used initially, a full cast being applied at a later date. The cast is radiolucent and the position of the bone should be checked by radiograph after the plaster has been applied. The distal circulation should be observed because a tight plaster may interfere with blood flow. All plasters should be checked 24 h after application. Cast-bracing involves the use of hinged and jointed casts – various segments are connected by specially designed hinges. This allows joint mobility and fracture stability, as well as patient mobility.

Traction

This is used to overcome the powerful pull of muscles, which may cause shortening or angulation. Traction may be fixed, e.g. a Thomas splint for femoral shaft fractures, or sliding (balanced) where the patient’s weight is balanced against an applied load. The patient’s weight and friction forces counter the applied traction. The patient can move the limb or can move about the bed while traction continues to act in the desired direction. Traction may be applied to the skin via adhesive tape or to bone via pins or wires. Skull traction can be effected by securing a pair of tongs to the skull and applying traction in the longitudinal axis of the neck. Tongs are now used less due to ‘halo’ traction.

Internal fixation

Wires

Kirschner (K) wires may be used to internally splint a fracture fragment in two separate planes, e.g. distal radial fracture or used with a figure of 8 tension band wire, e.g. fractures of the olecranon.

Screws

Stainless steel or titanium alloy screws are used. May be used to attach small bony fragment, e.g. fractures of malleoli or to lag two fragments in compression.

Plating

A plate is fastened to both fragments by screws (→ Fig. 17.2). Plates can be designed to compress a fracture, neutralize (support) a fracture compressed by lag screws or bridge a comminuted fracture.

Figure 17.2 A fracture of the radius and ulna fixed with plates and screws. The radial fracture is comminuted.

Intramedullary nail

A rod is passed along the medullary cavity of a long bone across the fracture and locked with transverse locking screws. It is used mainly for long bone fractures, e.g. femoral shaft fractures.

External fixation devices

The fragments are transfixed by pins or wires, which are then held in an external fixation device to immobilize the fragments. Difficult, comminuted fractures can be reduced and immobilized by this method. The fracture can be held while surgery for associated injuries, e.g. skin, vascular or nerve, is carried out.

Indications for internal fixation

• Failure to maintain adequate reduction by external methods

• Intra-articular fractures to secure good alignment of joint surfaces and prevent later osteoarthritis

• Need to avoid long periods of immobilization, e.g. elderly patient with fracture of femoral neck

• Patients with multiple injuries where internal fixation may facilitate nursing and patient mobility

• Where damage to other structures, e.g. vessels and nerves, requires stability for good results following repair

• Pathological fractures.

Immediate (at time of fracture)

Early (during the period of initial treatment)

Late (after the period of initial treatment)

Scene of the accident

Initial management at the receiving hospital

Classification by mechanism of injury

Cervical spine fractures and dislocations

Injuries most often occur because of RTAs or sport. A fall on the head with the neck forcibly bent, e.g. flexion and rotation. Subluxation or dislocation occurs with disruption of disc. Forced extension, e.g. a fall on the face or forehead, may occur resulting in cervical spine injury. If a cervical spine injury is suspected the first move should be to safeguard the cord by controlling neck movements. Do not allow the head to flex forward, and do not hyperextend the neck. Keep in a neutral position.

Thoracic spine

Flexion injuries result in crush or wedge fractures, which are usually stable. Such fractures may occur with minimal trauma if the vertebral body is weakened, e.g. osteoporosis or secondary deposits. Fracture-dislocations tend to occur at the thoracolumbar junction and are caused by flexion and rotation injuries, e.g. a fall from a height on to the shoulders or a heavy load falling on the flexed back. If the disc and posterior ligaments are disrupted the injury is unstable. Paraplegia is common in fracture-dislocations.

Lumbar spine

Compression fractures are the most common and may result from a fall from a height on to the heels. With a burst fracture a fragment of bone may be displaced posteriorly and cause damage to the cord or cauda equina syndrome.

Symptoms and signs

History of fall from height on to heels. Pain over lumbar spine. Pain and spasm in paravertebral muscles. Look for associated os calcis fractures or hip injury. Paraplegia.

Investigations

AP and lateral radiograph of lumbar spine (→ Fig. 17.3).

Figure 17.3 Lateral radiograph of the thoracolumbar spine. There is an anterior wedge fracture of the body of the 1st lumbar vertebra.

Treatment

Where there is no neurological damage and the fracture is not comminuted, immobilization in a moulded plastic or plaster jacket will suffice until union occurs. Pathological fractures will require fixation.

Fractures of the transverse processes

The most common are in the lumbar region. It may result from direct violence in a crushing injury or violent muscular contraction. Treatment is symptomatic. There is often severe soft tissue trauma and associated haematoma; prolonged pain may occur. Fractures of L5 transverse process suggestive of pelvic trauma.

Fractures of sacrum and coccyx

This may accompany fractures of the pelvis or occur as isolated fractures due to direct violence. Undisplaced linear fractures are treated symptomatically. Displaced fractures may injure sacral nerves with consequent neurological deficit.

Coccydynia

This causes chronic pain in the coccygeal region. It may follow a fall on the buttocks. The pain interferes with sitting. Treatment is by injection of LA and depot steroid or manipulation under anaesthesia (if fracture-dislocation). If conservative management fails excision of the coccyx may be required.

Types of spinal cord injury

The extent and level of cord damage is very important in determining recovery and final prognosis. Thoracic cord injuries tend to be complete. Incomplete injuries can be identified by the sparing of some tracts and these injuries tend to show much more recovery. The early picture is obscured by ‘spinal shock’ where all cord function ceases for 24–48 h.

Management and complications of cord injury

Nursing care

Good nursing care is essential and should always be in a specialized spinal unit. Objectives include: prevention of secondary complications; facilitation of maximum functional recovery; support for patients and family in adaptation to changed physical status; education of patients and relatives in all aspects of long-term care.

Physiotherapy

This involves care of both the chest and paralysed limbs initially. Later care involves help with strengthening non-paralysed muscles, adaptation to a wheelchair, relearning ability to balance, transfer from wheelchair to bed, toilet, etc. and bracing and gait training.

Occupational therapy

This helps adjustment to a lifetime of disability. Help is given to reach the highest levels of physical and psychological independence at home and at work. Help is provided with the activities of daily living, home alterations, recreation and work.

Social services

This provides help with finance, adaptation of home and employment.

Others

Long-term help with bladder problems, chronic pain, and sexual problems will be required.

Traumatic dislocation of the hip

Fractures of the proximal femur

The blood supply to the head of the femur comes from three sources:

• Retinacular vessels in the capsule

• Medullary vessels in the femoral neck

• Via the ligamentum teres.

The main source is via the retinacular vessels and these may be damaged in fractures of the femoral neck. Fractures may be classified as intracapsular (subcapital, transcervical), or extracapsular (basal, intertrochanteric → Fig. 17.4). Extracapsular fractures do not damage the blood supply to the femoral head and therefore there are no risks of avascular necrosis of the femoral head and non-union. They are most common in the elderly, especially females with osteoporotic bones when the traumatic cause is relatively trivial, e.g. a fall in the house. In the young patient they result from major trauma.

Figure 17.4 Fractures of the femoral neck. The arrowed line separates intracapsular (to the left) and extracapsular (to the right) fracture sites. Intracapsular fractures are associated with avascular necrosis of the femoral head.

Symptoms and signs

Elderly female. Minor trauma. Tripped over carpet. Tripped over pavement. Pain in the hip. Adduction of limb. Shortening and external rotation only if the fracture is displaced. Movements painful. Weight-bearing usually impossible. Beware hypothermia.

Investigations

• Radiographs in two planes (→ Fig. 17.5 AP view)

• Hb

• FBC

• U&Es

• Coagulation screen

• Blood sugar

• CXR

• ECG. In the elderly patient there is the possibility of intercurrent disease.

Figure 17.5 A subcapital fracture of the neck of the femur.

Complications

These are of the elderly undergoing surgery, e.g. pneumonia, MI, CVA, DVT and PE; 30% of elderly patients are dead within 6 months of the injury. Avascular necrosis of the femoral head. Non-union. Mal-union with varus angulation and shortening.

Treatment

General

Pain relief. Bed rest. DVT prophylaxis. Further investigation if pathological fracture suspected (CA, CXR, bone scan, long films to include joints above and below, myeloma screen).

Fracture

Surgery to allow nursing, mobilization, and rehabilitation:

• Intracapsular: undisplaced (fixed with screws); displaced – femoral head replacement, i.e. hemiarthroplasty, e.g. Exeter trauma stem or primary total hip replacement

• Extracapsular: cantilever device, e.g. dynamic hip screw; load sharing device, e.g. cephalomedullary nail, e.g. gamma nail.

Fractures of the femoral shaft

Supracondylar fractures (→ Fig. 17.6)

These are intra-articular or extra-articular. The distal fragment is pulled backwards by the gastrocnemius. The popliteal artery may be damaged by the distal fragment. Conservative treatment is by skeletal traction via the proximal tibia with the knee in about 30° of flexion. Internal fixation is required for all displaced intra-articular fractures (polyaxial/fixed angle locking plates, retrograde intramedullary nails).

Figure 17.6 A supracondylar fracture of the femur. In the lateral view, the distal fragment is tilted backwards and may damage the popliteal artery.

Isolated femoral condylar fractures

These are usually displaced so internal fixation is advised with lag screw or headless compression screw.

Tibial plateau fractures

In these fractures, vertical compression forces or strains drive the femoral condyle through the tibial plateau. Fragments of tibial plateau/condyle may be cleaved off, depressed, or both. Both condyles may be damaged. Displaced or depressed fragments should be reduced and internally fixed, often with support from a bone graft and a buttress plate.

Dislocation of the knee

This is an uncommon injury. It is usually associated with damage to the popliteal artery or local nerves. After reduction under anaesthesia any ruptured ligaments should be repaired. Immobilization in plaster then cast brace is required for several months.

Fractures

An avulsion or transverse fracture is caused by a violent contraction of quadriceps against resistance. A comminuted fracture is caused by direct violence, e.g. a blow from a bat or in an RTA.

Dislocation of the patella

This may be acute or recurrent and occurs laterally.

Isolated fractures of the fibula

These are uncommon. They are usually associated with tibial fractures and with direct violence. Beware common peroneal nerve injury in fractures of neck of the fibula. Exclude ankle injury, e.g. diastasis (see below). Treatment is by strapping or below-knee plaster until pain settles.

Classification (Fig. 17.7)

There are two main classification systems used. The Weber classification is used in everyday practice and describes the X-ray appearance of the fracture. The Lauge–Hansen describes the starting point and deforming force and generally is more useful for research purposes but is actually remarkably similar to the Weber classification. The Weber classification is based on the level of the fracture in relationship to the joint syndesmosis of the distal fibular. Three malleoli are described – medial, lateral (distal fibular) and posterior, which is the posterior most distal tip of the tibia.

Figure 17.7 Weber classification of ankle injuries.

Maisonneuve fracture (→ Fig. 17.8)

A twisting injury causes a high fibular fracture with a radiological normal ankle joint. The syndesmosis however is often disrupted along with rupture of the deltoid ligament. There is disruption of the interosseous tibiofibular ligament. Treatment involves syndesmosis screws and non-weight-bearing for 12 weeks.

Figure 17.8 Diastasis of the inferior tibiofibular joint with rupture of the interosseous membrane. There is an associated high fibular fracture (Maisonneuve fracture).

Os talus

This is rare. The blood supply is from distal to proximal and therefore fractures across the neck may result in avascular necrosis. It is usually caused by forced dorsiflexion. Undisplaced fractures are treated in plaster. The foot should be maintained in plantar flexion following closed reduction of displaced fractures; 8–12 weeks’ immobilization is required. Avascular necrosis leads to OA. Displaced fractures require internal fixation after reduction.

Os calcis

This is caused by a fall from height on to the heel. It may be bilateral. Look for fractures elsewhere, especially burst fractures of the spine. Conservative treatment is by bed rest and elevation of the legs to reduce swelling. Operative treatment is offered to non-smokers with fractures of moderate severity. Early subtalar fusion is often beneficial. Ankle exercises are required. Initial non-weight-bearing for 6–8 weeks. Partial weight-bearing on crutches is then permitted. Healing takes up to 10 weeks. Complications include pain, stiffness at the subtalar joint, and local nerve and tendon entrapment.

Shaft fractures

These occur with crushing injuries and are often multiple. Elevation of the foot followed by mobilization in a below-knee non-weight-bearing plaster for 6 weeks is required. If displacement is gross, manipulation or internal fixation may be required.

Stress fracture (‘march’ fracture)

This usually affects the second metatarsal neck and is caused by the stress of long hours of walking, e.g. new army recruits. It may not be apparent on an early radiograph but only show on a repeated radiograph when callus is forming. Treatment is a below-knee walking plaster for 6 weeks. In mild cases, rest only is required.

Lisfranc fracture

This is principally a dislocation of some or all of the tarso-metatarsal joints of the foot, particularly the 2nd metatarsal head fitting into the key stone of the cuneiform bones. Clinical suspicion is aroused due to massive swelling and potentially normal X-rays. X-rays should be repeated weight-bearing, anteroposterior, oblique and lateral and the dislocation may be emphasized. CT scan may confirm the diagnosis. Open reduction and internal fixation is required.

Dislocation of the sternoclavicular joint

This is uncommon. Usually the medial end of the clavicle dislocates forward and the deformity is obvious. Posterior dislocation is rare and may lead to tracheal compression. Treatment is usually symptomatic. Posterior dislocation requires open reduction to relieve tracheal compression.

Clavicular fracture

This is caused by falls on the outstretched hand or point of the shoulder. The bone usually breaks between the middle and outer third. Fractures of the outer end may be associated with fractures of the coracoid and damage to the coracoclavicular ligament.

Acromioclavicular joint

Scapular fracture

This is usually caused by direct violence. There may be extensive bruising. Treatment is by rest, analgesia, collar and cuff. Mobilize when pain allows. CT if suspicion of glenoid involvement.

Dislocation of the shoulder

The commonest form is anterior (95%), and is caused by a fall on the outstretched hand. In the younger patient the capsule is strong and does not tear. The glenoid labrum and capsule are avulsed from the bone, allowing recurrent dislocations to occur. In the older patient the capsule is torn – this heals after reduction. Recurrent dislocation is less common in the older patient.

Symptoms and signs

Fall on outstretched hand. Pain. Patient supports arm, which is abducted. The normal contour of the shoulder is lost. Check for axillary nerve damage – anaesthesia over skin at insertion of deltoid.

Investigations

Radiograph (→ Fig. 17.9): humeral head not in contact with the glenoid; check for associated fractures of the humeral head and neck.

Figure 17.9 Anterior dislocation of the shoulder joint. The humeral head lies below and medial to the glenoid (arrow).

Treatment

Reduction under GA or intravenous sedation. Two methods are available:

Kocher’s method

Flex the elbow to a right angle and apply slow gentle traction in the line of the humerus. Rotate the humerus externally using the forearm as a lever. Adduct the humerus across the trunk. Then internally rotate the humerus. Avoid this method in the elderly owing to risk of iatrogenic fracture.

Hippocratic method

Place the stockinged foot in the axilla and pull downwards on the arm. Use the toes to slip the head back into position. Confirm the position with radiograph. Immobilize the arm in a sling for 3 weeks.

Complications

Early complications include axillary nerve damage and associated fractures. Late complications include stiffness and recurrent dislocation. Complete rotator cuff tear in the elderly.

Recurrent dislocation

This usually follows damage to the glenoid labrum (Bankart lesion) or humeral head (Hill–Sachs lesion) at the time of original dislocation. Dislocation occurs on movement of the arm, especially if raised and externally rotated. Radiograph may reveal a depression on the humeral head (Hill–Sachs lesion).

Proximal humerus (→ Fig. 17.10)

This is usually due to indirect violence, i.e. a fall on the shoulder, often in the elderly.

Figure 17.10 A fracture of the neck of the humerus. This shows severe displacement. The axillary nerve is in danger with such a fracture.

Shaft of the humerus

This is caused by a direct blow or a fall on the outstretched hand. The fracture is usually oblique and may be displaced. Check for radial nerve damage (wrist drop and anaesthesia in the first web space on the dorsal aspect especially in midshaft fractures).

Supracondylar fracture

This is chiefly a fracture of childhood but may occur in adults. There is a history of a fall on the outstretched hand followed by pain and swelling around the elbow. The lower fragment is usually displaced, rotated and in extension. The brachial artery and median nerve are vulnerable to injury.

Lateral condyle/epicondyle

Lateral condylar fractures occurring in young children are injuries of the capitellar epiphysis. Displaced lateral condyles should be fixed to prevent valgus deformity and tarda ulnar nerve palsy due to traction. Lateral epicondylar avulsions are very rare and should be fixed if displaced.

Medial condyle/epicondyle

Medial condylar fractures are rare and should be fixed if displaced. Medial epicondylar fractures are more common and are associated with elbow dislocations (50%). They should be fixed if displaced by >0.5–1 cm or fragments need washing out of the joint.

Dislocation of the elbow

It is caused by a fall on the hand with the elbow partly flexed. Dislocation is almost always posterior. Occasionally there are fractures of adjacent bones. Median or ulnar nerve palsy may occur. Damage to the brachial artery is rare.

Fracture of the radial head

This varies from a fine vertical crack to severe comminution. There is localized tenderness over the radial head with minor injury. With comminution the elbow is painful and swollen with restriction of all movement. Minor cracks and undisplaced fractures may be rested in a collar and cuff sling for 2 weeks. Displaced large fragments may be internally fixed. Comminuted fractures may require excision or replacement of the radial head.

Fracture of the olecranon

This is caused by direct violence as an isolated injury, or as part of a fracture-dislocation of the elbow. Displaced fractures are internally fixed with tension band wires or lag screws.

Fractures of the radial and ulnar shafts

These injuries are common and are often open. They are usually caused by direct violence. An injury to the forearm usually affects the two bones, or one bone plus one radioulnar joint. A displaced fracture of the midshaft of either bone alone can occur if the radial head dislocates with an ulnar fracture (Monteggia’s fracture) or the distal radioulnar joint dislocates with a fracture of the radius (Galeazzi fracture). Radiographs of the forearm must therefore include both wrist and elbow joints. Occasionally direct violence fractures only one bone, e.g. the ulnar, as when lifting up the flexed arm to ward off a blow. In children, fractures are of the greenstick type with angulation. In adults the fractures are transverse or oblique.

Fractures of the distal radius

Colles’ fracture (→ Fig. 17.11)

This is a dorsally displaced fracture in the elderly 2.5 cm from the wrist joint. It is common in elderly osteoporotic women following a low-energy fall.

Figure 17.11 Colles’ fracture. (A) Lateral view. (B) Anteroposterior view.

Distal radial fracture

A similar fracture is found in younger adults. While there is not the same degree of dorsal cancellous bone collapse as with the osteoporotic Colles’ fracture, the high energy nature of the injury often leads to comminution or intra articular extension of the fracture. These are more aggressively treated by surgery due to higher patient demand.

Symptoms and signs

Fall on outstretched hand. Pain. Limitation of wrist movement. ‘Dinner fork’ deformity. Check for distal neurovascular deficit.

Investigations

Radiograph in two planes (→ Fig. 17.12): distal fragment is displaced dorsally, radially (with pull-off of the ulnar styloid) and supinated; check for intra-articular fracture lines and associated scaphoid fracture.

Figure 17.12 A radiograph of the wrist (lateral view) showing a typical Colles’ fracture. There is apex volar angulation, dorsal displacement, and impaction.

Treatment

Undisplaced or greenstick fractures require immobilization in a below-elbow plaster for 3–4 weeks. Significant displacement requires manipulation under general or regional anaesthesia (Bier’s block). The fracture is disimpacted by traction and increasing the deformity. The distal fragment is levered over the proximal, the wrist flexed, ulnar deviated and pronated. A dorsal plaster slab is applied to hold this position. A check radiograph is taken and the arm supported in a sling. A further radiograph is taken 1 week later to check reduction. Swelling has usually subsided by this time and the plaster is completed and the sling abandoned. The plaster is removed at 6 weeks and exercises commenced. Operative treatment is required for intra-articular fractures (especially in the young) and failed reduction or failed plaster immobilization.

Complications

Stiffness and oedema of the hand. Mal-union with angulation. This may be associated with pain from subluxation of the inferior radioulnar joint. Median nerve symptoms occur but usually subside spontaneously. Later rupture of the tendon of extensor pollicis longus may occur where it crosses the fracture. Complex regional pain syndrome.

Fracture of the scaphoid

Caused by a fall on the outstretched hand or a blow to the palm of the hand. The blood supply to the bone comes from distal to proximal, and hence there is a risk of avascular necrosis of the proximal fragment. The scaphoid spans both rows of carpal bones hence the high risk of non-union.

Dislocation of the carpus

Commonly missed. Caused by a fall on an extended hand. If the radiograph looks unusual, especially the lateral view, obtain specialist advice. Volar (anterior) dislocation of the lunate is the commonest and may cause acute median nerve compression. Check for associated scaphoid fracture. Closed or open reduction is performed. Methods of immobilization are controversial but application of a plaster ± K wires for 6–8 weeks may be required.

Fractures at the base of the thumb

Extra-articular fractures can usually be treated conservatively by manipulation and plaster casting. Intra-articular fractures of the thumb may produce late OA. Bennett’s fracture is oblique and the small fragment is on the ulnar side of the base of the first metacarpal where the deep oblique ligament attaches. Most are treated with closed reduction and K wires under GA, but occasionally open reduction and internal fixation is required. Late OA is rarely seen.

Fractures of the metacarpal bones

These are caused by direct violence or by punching with a closed fist. Very important to identify the ‘fight bite’ injury where a tooth penetrates the MCP joint. Condition often missed. Requires wash out.

Fractures and dislocations of the phalanges

These are often serious injuries and may be associated with tendon and nerve damage.

Fractures of the terminal phalanges

These are usually crush injuries and may be open. There may be subungual haematoma that contributes to the pain. The latter can be drained by piercing the nail with a hot wire, giving instant relief. Open fractures are treated with wound toilet, leaving the wound open, tetanus toxoid and broad-spectrum antibiotics. Occasionally, partial amputation of the finger is required.

Mallet finger

This injury is caused by ‘stubbing’ a finger when it is actively extended. Forced passive flexion leads to avulsion of the extensor tendon from the base of the terminal phalanx often with a flake of bone. Examination reveals a finger in which the distal phalanx is flexed and cannot be actively extended. Treatment is by immobilization of the distal interphalangeal joint in a ‘mallet finger’ splint, which hyperextends the terminal interphalangeal joint while allowing flexion of the proximal interphalangeal joint. The splint is worn for 6 weeks. Occasionally healing does not occur but the disability is usually slight, although it may be more pronounced and require fusion of the distal interphalangeal joint.

Osteoarthritis (osteoarthrosis, OA)

This is a term applied to degenerative disease of a joint caused by wear and tear that affects the articular cartilage and subchondral bone. At first, the synovial membrane is normal but later thickening and fibrosis occurs. OA may be primary or secondary. In the former there is no underlying cause. It may arise as a result of senile changes and may affect more than one joint. Secondary OA occurs if there has been previous damage to the joint, e.g. congenital deformity, trauma, infection, avascular necrosis, gout, haemophilia.

Symptoms and signs

Pain. Stiffness. Deformity. Pain increases in severity as the disease progresses. Sleep is often disturbed. Synovial thickening and bony enlargement of joint because of osteophytes. Effusions. Tenderness. Loss of movement. Crepitus. Fixed deformities. Disturbances of gait.

Investigations

Radiographs (→ Fig. 17.13): narrowing of joint space, subchondral bone sclerosis, subchondral cysts, osteophytes, evidence of other underlying pathology. Symptoms do not necessarily correlate with the severity of radiological changes.

Figure 17.13 There is osteoarthritis of the right hip joint. The joint space is diminished and there is sclerosis of the surrounding bone. On the left side, the patient has had an arthroplasty (hip replacement).

Treatment

Principles of treatment involve pain relief, improvement of mobility and correction of deformity. Management may be conservative or surgical.

Conservative

Analgesia: start with mild analgesia, e.g. paracetamol; NSAIDs are usually required eventually.

• Lose weight

• Walking stick or shoe raise

• Physiotherapy, i.e. heat treatment or short-wave diathermy

• Changing occupation to a lighter job.

Surgical

Disturbance of sleep, severe uncontrolled pain and gross lack of mobility are indications for surgery. The following procedures may be undertaken depending upon the level of symptoms and joint involved:

• Arthroscopy or open debridement: occasionally synovectomy and removal of osteophytes can give temporary relief

• Replacement arthroplasty (→ Fig. 17.13): most joints can be replaced by artificial joints, e.g. hip and knee

• Osteotomy: weight-bearing axis redistributes weight commonly to the lateral side. Pain relief is often dramatic and failure of the procedure is slow

• Excision arthroplasty: for small joints, e.g. small toes

• Arthrodesis: surgical fusion of the joint, relieves pain, e.g. first MTP joint in hallux rigidus.

Rheumatoid arthritis (RA)

Only surgical aspects of management will be dealt with here. (The reader is referred to a textbook of medicine for the details of the symptoms and medical management of this disease.) Surgery is undertaken to improve function, not for cosmetic effect. Procedures include:

Loose bodies

These may occur in any joint but the knee is by far the commonest site. Causes include osteochondritis dissecans (see below), detached osteophytes in OA, osteochondral fractures, torn menisci and synovial chondromatosis, where cartilaginous nodules form in the synovium and may become detached.

Osteochondritis dissecans

In this, an area of bone with its overlying articular cartilage becomes necrotic, separates and drops into the joint cavity as a loose body. It is associated with local trauma (50%).

Neuropathic joints (Charcot’s joints)

A diffuse destructing deformity and dislocation often found in diabetes. A joint which has lost pain and proprioception appreciation is subject to harmful stresses and strains. Destruction of the joint results. The patient usually presents with a painless, deformed joint. Causes include diabetic neuropathy, tabes dorsalis, syringomyelia and leprosy. Vibration sense, position sense and deep pain sensation are absent or reduced. Treatment requires non-weight-bearing immobilization followed by a graduated return to ankle foot orthoses. Arthrodesis and arthroplasty are usually unsuccessful. Supporting appliances may be the most appropriate treatment.

Haemophilia and related disorders

The main orthopaedic problems relate to acute haemarthroses and bleeding into muscles. They may occur spontaneously or as a result of injury, which may be minor. Recurrent bleeding into the same joint results in degenerative changes, capsular fibrosis, contracture and deformity. The knee, elbow and ankle are the joints most frequently affected.

Design of joint replacements

Practice of joint replacement

Meniscus tears

This is a common knee injury. The medial is affected more often than the lateral. It occurs in patients whose occupation involves kneeling, crouching, or trauma, e.g. miners, footballers.

Ligamentous damage

Damage to the collateral ligaments and cruciate ligaments occurs frequently in sportsmen. Strains may be associated with an effusion into the joint and tenderness over the affected ligament. In contrast to complete tears the joint remains stable. Strains settle with rest and support followed by graded exercises.

Bursae around the knee

Sprained ankle

The anterior talofibular ligament is the most common ankle ligament that may be torn during an inversion injury. Pain, swelling and tenderness occur below and in front of the lateral malleolus. Treatment is by analgesia, physiotherapy and occasionally an ankle foot orthosis.

Rupture of the Achilles tendon

This usually occurs during sport, e.g. tennis or due to a missed step. The patient feels ‘something give’ and feels like ‘being kicked in the back of the heel’. Examination usually reveals a gap in the tendon. The calf squeeze test is positive. Conservative treatment is by plaster immobilization in full plantar flexion followed by progressive plasters up to the neutral position. Surgical repair may be necessary in the young, active patient and is followed by immobilization in plaster to reduce the risk of re-rupture. Operative repair is required for re-rupture and delay in diagnosis of >1 week.

Plantar fasciitis

This occurs in late middle age. The pain is under the heel. In the younger patient it may be associated with Reiter’s disease. The pain is often worse on standing after a period of rest and improves somewhat with walking. Examination reveals tenderness at the attachment of the plantar fascia to the under surface of os calcis. A lateral radiograph may show an associated calcaneal spur. Treatment is by a soft heel pad, or local injection of steroid and local anaesthetic or both. The condition is self-limiting.

Impingement syndrome

Mechanical impingement of the rotator cuff muscles on the under-surface of the acromion can cause inflammation and pain with overhead activities. The insertion of supraspinatus is a relatively avascular area susceptible to repeated trauma and degeneration. Pain may be felt in the mid-arc of abduction with positive impingement tests – shoulder forward flexed 90° and internal rotation impacts supraspinatus tendon between acromion and greater tuberosity.

Frozen shoulder

Now thought to be due to fibrosis of the capsule of the shoulder joint. Often no predisposing cause is found. There are no adhesions or synovitis. Stiffness and pain predominate with loss of external rotation. May be primary of unknown aetiology or secondary, e.g. trauma. More common in diabetics.

Rotator cuff tears

Most commonly affects supraspinatus but can involve subscapularis and infraspinatus. Usually occurs in a tendon that is already degenerate. It follows trivial trauma or normal everyday activity. There is a sudden pain in the shoulder and an inability to initiate abduction. If initial abduction can be started passively (e.g. by tilting the body to the side to initiate abduction by gravity) deltoid can continue abduction. Diagnosis may be confirmed by USS, CT or MRI. Surgical treatment may be required for large tears.

Rupture of the long head of biceps

This usually occurs in a previously diseased tendon. There is acute pain, tenderness and ‘bunching up’ of the muscle in the lower part of the upper arm when the elbow is flexed. There is little residual functional disability.

Tennis elbow

This is chronic inflammation or degeneration of the extensor carpi radialis brevis at its origin on the lateral epicondyle. It affects anyone whose work involves extending and twisting the forearm. In some cases there is no obvious cause. There is pain on the outer side of the elbow radiating down the back of the forearm. It becomes worse on gripping. Tenderness is localized to the lateral epicondyle. Extension of the fingers and wrist against resistance exacerbates the pain. Treatment is by rest and injection of local anaesthetic and hydrocortisone. Surgery is rarely indicated.

Golfer’s elbow

This is similar to tennis elbow but affects the medial epicondyle. Pain occurs on hyperextending the fingers and wrist. Treatment is by rest and injection of local anaesthetic and steroid. If the latter treatment is given, remember the close proximity of the ulnar nerve.

Student’s elbow (olecranon bursitis)

This occurs owing to prolonged pressure over the olecranon bursa, e.g. a student studying long into the night and resting the head in the hand with the elbow on the table. For obvious reasons, the condition is uncommon in present-day students. Examination reveals a swelling over the olecranon, which may be acutely inflamed. In the acute phase, aspiration (occasionally pus is obtained) and antibiotics are required. NSAIDs are usually given for pain relief. In the chronic phase, straw-coloured fluid is aspirated. Surgical excision may be required.

Tenosynovitis

This is inflammation of a tendon sheath. It is caused by the trauma of repetitive movements and affects the tendons of the fingers and thumb, especially dorsally, where they cross the wrist within their synovial sheath. There is localized tenderness and crepitation on movement of digits. Treatment is by rest, local splinting and NSAIDs. A specific form affects the tendon sheaths of abductor pollicis longus and extensor pollicis brevis as they cross the radial styloid (De Quervain’s tenosynovitis). Pain occurs at the site and is exacerbated by gripping and by extending the thumb. Forced flexion of the thumb with ulnar deviation of the wrist exacerbates the pain. Treatment in the acute phase involves splints and local injection of hydrocortisone. Chronic cases require surgical division of the tendon sheath.

Ganglion

A ganglion is a cystic swelling in relation to a joint or tendon sheath. It may represent cystic-myxomatous degeneration of fibrous tissue. It is common on the dorsum of the hand, and also occurs in relation to the wrist and ankle. It is a painless, cystic swelling that is fluctuant and transilluminates, and is filled with a crystal clear gel (some authorities believe it is a protrusion of synovium through an opening in a joint or fibrous sheath and that the fluid is derived from synovial fluid). Treatment is aspiration or surgical excision. The latter should be done under GA or brachial block using a tourniquet as they often extend down inside the underlying joints. Recurrence is less common when treated surgically.

Trigger finger

The fibrous flexor sheath thickens and the lumen narrows. The narrowed area causes friction against the tendon, creating a localized nodule in the tendon. The condition occurs at the level of the metacarpal head or neck. As the nodule passes through the area of stenosis, a click or snap is felt and the digit ‘triggers’. Sometimes, the digit frankly locks in flexion and cannot be extended. If the finger is fully flexed the patient may have to extend it passively. A nodule may be palpable at the site of thickening. Spontaneous resolution may occur. Around 70% will respond to steroid injection to the entrance of the tendon sheath. Surgical treatment may by required and is by longitudinal division of the A1 pulley at the opening. Multiple ‘triggering’ digits should arouse the suspicion of RA.

Dupuytren’s contracture

This is a condition of the palmar fascia involving nodules and contractures. Aetiology is unknown but it is associated with family history, diabetes, alcoholism, liver disease and antiepileptic drugs. It may be associated with Peyronie’s disease and retroperitoneal fibrosis.

Ulnar neuritis

The ulnar nerve lies in a groove behind the medial epicondyle. Pressure or chronic friction may occur in the groove. Cubitus valgus (increased carrying angle) may stretch the nerve. Symptoms include pain in the forearm, paraesthesia in the ulnar one and half fingers and wasting of the small muscles of the hand supplied by the ulnar nerve. EMG studies confirm the diagnosis. Treatment is by decompression or by transposition of the ulnar nerve anterior to the medial epicondyle.

Carpal tunnel syndrome

In this condition the median nerve is compressed in the carpal tunnel. It may be associated with pregnancy, RA, myxoedema, OA, anterior dislocation of the lunate, and arteriovenous fistula at the wrist for dialysis. Middle-aged women are most affected.

Metatarsalgia

This is pain under the metatarsal heads. It is caused by a dropped transverse arch, often in elderly obese ladies. It is tender over the second and third metatarsal heads with callosities. Treatment is with a weight-relieving insole. Morton’s metatarsalgia is due to a plantar digital neuroma, probably due to chronic trauma at the confluence of the medial and lateral plantar nerves against the metatarsal transverse ligament. It also affects middle-aged women. Usually it affects the cleft between the third and fourth toes. Treatment is weight-relieving insoles or division of the metatarsal ligament. If symptoms do not settle, wide-toe box shoes and steroid and local anaesthetic infiltration or exploration and excision of neuroma may be necessary. Other causes include stress fracture, plantar warts, inflammatory conditions (e.g. RA), Freiberg’s disease.

Hallux valgus

This is common in females. The first metatarsal deviates medially and the great toe laterally creating a bulge often covered with a ‘bunion’ due to a thickened overlying bursa. The great toe may overlap or under-ride the second toe. It may be a result of wearing unsuitable footwear, especially in adolescence. It is often familial. Metatarsalgia may co-exist.

Hallux rigidus

This is OA of the first metatarsophalangeal joint. It is a common condition that occurs in young adults, but the cause is unknown. There is pain on walking, especially ‘pushing off’, and a stiff, painful, enlarged joint. Radiographs show OA. Treatment in mild cases is by a metatarsal bar in the shoe. Severe cases require arthrodesis.

Hammer toes

This is a toe (usually the second) with a fixed flexion deformity of the proximal interphalangeal joint and compensatory hyperextension of the adjacent joints. Painful overlying corns occur. Treatment is by arthrodesis or excision of the proximal interphalangeal joints with extensor tenotomy.

Mallet toe

This is a toe with flexion deformity of the distal interphalangeal joint with a corn at the tip of the toe or over the joint. Distal interphalangeal joint fusion is indicated.

Acute osteomyelitis

This is a disease of growing bones or immunosuppressed or diabetic adults. It is usually due to Staphylococcus aureus, and rarely due to Streptococci, Pneumococci, Haemophilus or Salmonella. The infection usually starts at the vascular metaphysis of a long bone or centre of a short bone. Common sites include the lower end of the femur, upper end of the tibia, humerus, radius, ulna and vertebral bodies. Suppuration occurs and pus under tension causes bone necrosis. Pus breaks out under the periosteum, strips it up, and penetrates through, forming a sinus. Alternatively, the pus can decompress into the joint causing septic arthritis. Necrotic bone is called a ‘sequestrum’. New subperiosteal bone forms around the dead bone forming a shell (involucrum).

Acute pyogenic arthritis

This is a blood-borne infection, especially in infants. Staphylococci, Streptococci and Gonococci may be causative organisms. It may arise following osteomyelitis, where the metaphysis is intracapsular, e.g. hip joint. It is a complication of RA in patients on steroids. Occasionally it follows penetrating injuries of joints.

Chronic osteomyelitis

This may follow acute osteomyelitis but is more common following surgery for an open fracture, especially when foreign material is implanted. It may be chronic from the outset, e.g. tuberculosis.

Osteoma (‘ivory’ osteoma)

This is a growth from the surface of bone. It is common on the surface of the vault of the skull. A smooth, non-tender mound, it rarely causes symptoms. If symptomatic, it can be cured by excision.

Osteoid osteoma

It usually occurs in long bones or spine in young males. There is severe continuous boring pain – usually worse at night and with characteristic marked relief by aspirin. It is probably not a true neoplasm. Radiographs show dense sclerosis surrounding a small central lucent nidus (osteoid). Treatment is by radioablation (90% successful), which gives dramatic relief of pain. 50% burn out.

Chondroma

A cartilaginous tumour, common in the phalanges and metacarpals. An enchondroma is a chondroma growing in the centre of a bone. A periosteal chondroma is a chondroma growing on the surface of a bone. Osteochondroma is a cartilage-capped bony outgrowth (commonest bone tumour, malignant potential, especially if >2 cm or multiple). Treatment is indicated only when the swelling is large, when excision should be undertaken. Occasionally multiple enchondromatosis occurs (Ollier’s disease) associated with AV malformations (Maffucci’s). These have significant future malignant potential.

Fibroma and fibrous dysplasia

This is a spectrum of conditions with failure or partial failure of ossification replaced by fibrous tissue. These are usually asymptomatic and often regress at puberty or after a fracture.

Bone cysts

These are fluid- or blood-filled cavities. They vary from multiloculated cysts containing clear fluid in children and adolescents to large aneurysmal bone cysts that may cause ‘bulging out’ of one side of a bone. Pathological fractures are common. Treatment is by excision and bone grafting.

Primary

Osteosarcoma (osteogenic sarcoma)

This is the most common primary tumour of bone. It occurs under the age of 30 years and is more common in males. It occurs in long bones. In older patients it is usually associated with Paget’s disease; in the young it commonly affects the lower end of the femur or upper end of the tibia. It usually affects the metaphysis. Spread is via the bloodstream to the lungs; 10–20% have metastases at presentation.

Symptoms and signs

Bone pain. Swelling. Limp. Cough due to lung metastases. Tumour grows rapidly. Hot, tender swelling on examination.

Investigations

• Radiograph (→ Fig. 17.14): bone destruction, grows out of cortex elevating periosteum with deposition of subperiosteal bone (Codman’s triangle), radiating spicules of bone (‘sunray’ spicules), soft tissue invasion

• ESR ↑

• Alkaline phosphatase ↑

• CT scan: shows invasion of the tumour, lung secondaries

• Biopsy.

Figure 17.14 Osteogenic sarcoma of the lower end of the femur showing ‘Codman’s triangle’ (top arrow) and ‘sunray spicules’ (bottom two arrows).

Treatment

Classically, amputation was carried out as soon as diagnosis was made. Current treatment involves pre-adjuvant chemotherapy, restaging and then wide excision. If multiple pulmonary metastases at time of presentation, treatment is by chemotherapy alone. Solitary pulmonary metastases may be resected.

Prognosis

The 5-year survival is 60–70%, with pre-adjuvant chemotherapy followed by surgery.

Secondary

Secondary deposits occur in bone from the lung, thyroid, breast, prostate and kidney.

Symptoms and signs

Bone pain. May be past history of primary tumour or primary may not be apparent. Pathological fracture. Full clinical examination of likely primary sites.

Investigations

• Radiograph individual bone: osteolytic, mixed or osteosclerotic (prostate) lesions

• Bone scan (→ Fig. 17.15)

• Alkaline phosphatase ↑

• PSA ↑

• CA125

• TFTs

• calcium ↑.

Figure 17.15 A bone scan showing secondary deposits (hot spots) in the bony skeleton, especially in the ribs.

Treatment

Severe bone pain at one site may be treated by local radiotherapy or systemic irradiation (thyroid with radio-iodine).

• Pathological fractures are treated by internal fixation and radiotherapy

• Hormonal manipulation. Breast responds to oophorectomy. Prostate responds to hormone manipulation.

Osteoarthritis of the spine

In this condition, disc degeneration causes narrowing of the space between vertebral bodies. The posterior intervertebral facet joints may become osteoarthritic. Osteophytes form and may encroach on nerve roots.

Prolapsed intervertebral disc

This is a common cause of low back pain and sciatica. There is often a history of pain or mild injury, e.g. while lifting. Backache and radicular pain occur. Most disc prolapses are posterior and pass lateral to the posterior longitudinal ligament (paracentral disc) causing compression of the transiting nerve root. Far lateral discs may compress the exiting nerve root also (Fig. 17.16) Central disc prolapses may compress the cord (cord compression) or more commonly, as discs herniated at the level of the cauda equina, cause cauda equina syndrome.

Figure 17.16 Prolapsed intervertebral disc. Radiculopathy in relation to transiting and exiting nerve roots. Paracentral disc lesions compress the transiting nerve. Far lateral disc lesions compress the exiting nerve.

Symptoms and signs

Back pain

Worse on movement, coughing, straining. May radiate to buttock and thigh without nerve root entrapment. Associated spasm and loss of lordosis. Restricted movements.

Nerve root compression

Most commonly L5 or S1. Dermatomal distribution of pain and anaesthesia. Segmental weakness (L5 – big toe extensor, S1 – foot evertors). Sciatic stretch test (reproduction of radicular leg pain on passive straight leg elevation and foot dorsiflexion). Depressed reflexes, e.g. L3/4 – depressed knee jerk, L5/S1 – depressed ankle jerk.

Cauda equina syndrome

Absolute surgical emergency. Compression of sacral outflow, saddle paraesthesia. Reduced anal sphincter tone. Reduced bladder coordination, painless retention and overflow. Loss of anal reflex. Bilateral leg symptoms.

Investigations

• Radiograph: often of little help, mild scoliosis, loss of lumbar lordosis, may be loss of disc spacing in chronic cases

• MRI (→ Fig. 17.17).

Figure 17.17 MRI showing a prolapsed intervertebral disc (arrow).

Treatment

Need correlation of symptoms with MRI.

Conservative

Reassurance. Analgesia. Physiotherapy. Avoid prolonged bed rest. Mobilization.

Surgical

An absolute indication for urgent surgery is bladder paralysis. Muscle weakness is also an indication for urgent surgical assessment. Other indications include failed conservative management for 6 weeks to 3 months: repeated attacks. Operative treatment involves surgical removal of the sequestrated part of the disc. This may be carried out by the open method, i.e. discectomy, partial laminectomy and removal of the disc material pressing on the nerve root, or by microdiscectomy, a minimally invasive technique using a special microscope to view the disc and nerves.

Spondylolisthesis

In this condition, one vertebra slips forward relative to the one below, usually L5 on S1 or less commonly L4 on L5. A classification of spondylolisthesis is shown in Table 17.2.

Scheuermann’s disease (adolescent kyphosis)

The ring epiphyses of the vertebral bodies are affected by osteochondritis. The vertebral bodies grow abnormally and become wedge-shaped. The condition occurs between 12 and 18 years.

Ankylosing spondylitis

This affects young adults, males more commonly than females. It usually starts in the sacroiliac joints and extends to involve the whole spine. Ossification occurs in the ligaments of the spine and intervertebral discs and the spine is converted to a solid column of bone with an increasing kyphosis (bamboo spine). There is an association with HLA-B27.

Cervical spondylosis

This is a degenerative condition of the cervical spine with narrowing of the intervertebral discs and osteophyte formation of the adjacent vertebral bodies. OA develops in the synovial intervertebral joints. The condition is common in the middle-aged and elderly. It may cause pressure on the nerve roots or the cord itself.

Symptoms and signs

Painful, tender, cervical spine with reduced neck movement. Pain may radiate over the occiput and to the shoulders. When nerve roots are involved pain radiates into the arm and hand. Stiff neck, limited movement of neck. Diminished reflexes in the arm, dermatomal sensory loss, signs of lower motor neuron weakness. Rarely bladder involvement from cord compression. Rarely spasticity of legs.

Investigations

• AP and lateral radiographs of cervical spine (→ Fig. 17.18): narrowing of disc space, lipping of vertebrae, osteophytes, sclerosis of posterolateral joints with encroachment on foramina

• If neurological symptoms, MRI.

Figure 17.18 A lateral radiograph of the cervical spine showing cervical spondylosis. There is gross anterior lipping of C5, 6 and 7. There is marked narrowing of the disc spaces.

Differential diagnosis

Thoracic outlet syndrome, shoulder disorders, carpal tunnel syndrome, peripheral neuropathy, spinal cord tumour, syringomyelia.

Treatment

Reassurance and symptomatic treatment in mild cases. NSAIDs, collar, short-wave diathermy. Gentle traction. The need for surgery is rare but may be required to decompress the nerve roots or cord.

Cervical disc prolapse

This should be distinguished from cervical spondylosis. It usually occurs in a young adult.

Osteomalacia and rickets

Vitamin D deficiency causes the failure of osteoid to ossify. Rickets is the childhood form of osteomalacia. In children classical deformities occur, i.e. bowing of the femur and tibia, large head, chest deformity with thickening of the costochondral junctions (rickety rosary), enlarged epiphyses. In adults, bone pain and pathological fractures occur (especially in the elderly with associated osteoporosis). Treatment is with vitamin D and calcium. Orthopaedic correction may be required for severe deformities in children.

Osteoporosis

This is a reduction in bone mass per unit volume. The causes are multifactorial. It is common in postmenopausal women. Pathological fractures are common (hip, wedge fractures of vertebrae, Colles’ fracture). Radiograph shows osteopenia, i.e. loss of bone density and cortical widening to increase bending stiffness, when 30–40% of bone mass has been lost. Treatment is difficult but should correct any underlying cause. Calcium and vitamin D should be given if the diet is deficient. Bisphosphonates inhibit bone resorption. HRT helps prevent postmenopausal osteoporosis at the expense of a small risk of endometrial carcinoma.

Hyperparathyroidism (→ Ch. 11)

Pathological fractures may occur.

Paget’s disease of bone

This is a difficult disease to categorize but is included here for convenience. The aetiology is unknown. Disorderly bone resorption and replacement leads to softening, increased vascularity, painful enlargement and bowing of bones. It occurs in middle to old age and is more common in males. The skull, vertebrae, pelvis and long bones are affected. Some cases are symptomless, being picked up on routine radiograph (→ Fig. 17.19). Complications include compressive symptoms due to skull enlargement (e.g. blindness, deafness, cranial nerve entrapment), paraplegia, pathological fractures, high-output cardiac failure due to vascularity of bone. Osteogenic sarcoma may develop after many years. In mild cases no treatment is required. In severe cases, calcitonin and bisphosphonates may help.

Figure 17.19 Paget’s disease of bone. The pelvic bones are thickened and patchily sclerotic.

Adolescent idiopathic scoliosis

This is more common in girls aged 10 onwards. It is usually convex to the right and thoracic curves are most common.

Development dysplasia of the hip (DDH)

This describes a wide spectrum of hip abnormalities ranging from mild acetabular dysplasia to complete dislocation of the hip secondary to capsular laxity and mechanical factors. This condition was formerly known as congenital dislocation of the hip (CDH). The incidence is 1.5 : 1000 live births and girls are affected more than boys (85% girls) and the left hip is more commonly affected than the right. There are hereditary factors – an increased risk if one parent has DDH. There is an association with breech delivery and the first born child.

Irritable hip

This usually occurs under the age of 10 years and is more common in boys. The aetiology is unknown and the condition is self-limiting, the diagnosis being one of exclusion of other conditions.

Perthes’ disease

This is a non-inflammatory deformity of the proximal femur secondary to vascular insult leading to osteonecrosis of the proximal femoral epiphysis. It is bilateral in 10%, is commoner in boys and usually occurs between 4–8 years, being maximum around 7–8 years.

Slipped upper femoral epiphysis

This occurs from ages 10–18 years and boys are more affected than girls. The child may be overweight and may have delayed sexual development in some cases. The capital femoral epiphyses appear slipped downwards and backwards (in actual fact, the neck is the segment displaced); 25% are bilateral, of which 15–30% occur simultaneously.

Osteochondritis of the tibial tubercle (Osgood–Schlatter disease)

This is a common condition affecting adolescent boys in which the epiphyses of the tibial tubercle are involved (strictly speaking it is an apophysis). (An apophysis is an insertion of a tendon and does not contribute to longitudinal growth of a bone like an epiphysis.)