Growing Specialty Orthopedic surgery is a broad and actively growing surgical specialty.

It concerns the nonoperative and operative treatment of disorders of the musculoskeletal system including bones, joints, muscles, tendons, ligaments, and nerves. The orthopedic surgeon must be familiar with the normal growth and development of the musculoskeletal system, as well as disorders that can arise from genetic or developmental abnormalities, trauma, infection, inflammatory processes, the degenerative process, and neoplasm. In every patient, the orthopedic surgeon will work hard to find nonsurgical solutions for the patient's condition. However, surgical treatments are often necessary to preserve or restore musculoskeletal function, assist in healing, or palliate pain. Anatomy of Long Bones Much of an orthopedic surgeon's practice concerns treatment of the "long bones." Long bones generally consist of an epiphysis (the portion of the bone on either end which usually contains an articular surface). The epiphysis is formed from an epiphyseal ossification center at either end of most long bones separated from the metaphysis of the long bone by the growth plate (Fig. 43-1). After skeletal maturity, the ends of bones continue to be referred to as the epiphyseal region. The metaphysis of a long bone is the region immediately below the growth plate or its remnant. The metaphysis tapers to become the shaft or diaphysis of the long bone. The cells that synthesize bone matrix (osteoid) are the osteoblasts. Essentially all surfaces of the bone are covered with osteoblasts or osteocytes. Osteoblasts, which are active in bone synthesis, are noted histologically to be large with abundant cytoplasm. Quiescent osteoblasts are thin and "flat." Joint Anatomy Mobile joints are called diarthrodial joints. In such joints, there is no direct bone to bone contact. Instead, weight bearing and motion are accomplished through intervening surfaces or hyaline (articular) cartilage. Stability of the joints is accomplished through musculotendinous action and limited and guided by the presence of ligaments and the joint capsule itself. The joint capsule also serves to enclose the lubricating synovial fluid, which provides nutrition to the chondrocytes in the articular cartilage and facilitates gliding motions between the two cartilage surfaces. Muscle Anatomy Skeletal muscle is, by weight, the single largest tissue in the body. The structure of skeletal muscle is indicated in Fig. 43-3. Muscle contraction is accomplished by adenosine triphosphate driven sliding motions between actin and myosin filaments, driven by the adenosine triphosphatase of the myosin molecule. Precisely arranged, actin and myosin containing sarcomeres form the basic contractile apparatus, the myofiber. Multiple myofibers compose a muscle fiber and multiple muscle fibers compose the fascicle. In turn, multiple fascicles form a muscle.

Organization of skeletal muscle from the microscopic to the macrostructural level.

[Reproduced with permission from Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994, p 91.]

Basic Biomechanics An understanding of basic biomechanics is critical to an orthopedic surgeon. Bone generally is considered to be a rather static rigid structure; however, this is a misconception. Not only are the cells and matrix of the bone subject to regular turnover, the bone itself normally flexes and bends to a surprising degree. Biomechanical engineers use the words stress and strain to describe the material properties of bone, and tissue, as well as orthopedic implants. The word stress refers to force exerted per unit area. The word strain is used to define deformation of a material when placed under stress. The mechanical properties of most materials can be displayed in a stress/strain curve. The stiffness of a material is expressed by the slope of such a curve. Strain in a bone or other material is usually elastic (or completely reversible)

under low levels of stress. When the exerted force causes reversible changes to the material, plastic deformation or mechanical failure (fracture) is said to occur. The mechanical behaviors of a substance can be changed substantially by the presence of focal defects in the material. For example, a bone will break much more easily at or near a small defect of the bone. This is due to concentration of stress forces in this area, a so-called stress riser. This can occur at the site of a destructive lesion, such as a tumor, or more importantly, can result from surgical intervention with the creation of screw holes (Fig. 43-4). A stress riser is a hole or defect in a material that produces a concentration of forces. This increases the risk of the material failing under conditions that, without the stress riser, would not lead to failure of the material.

Biomechanics of Skeletal Motion The joints move by the action of muscles on the bone through their tendinous attachments. The effect of a muscle contraction depends on its origin and insertion and on the constraints and geometry of the intervening joint or joints. The effect of most muscles can be usefully viewed as a lever arm. The amount of force needed to move an object is heavily influenced by the length of the level arm (Fig. 435). Contraction of a muscle unit with a short lever arm results in a large application of force, generally at a low speed. A longer lever arm will diminish the amount of effective force that can be exerted, but can result in a great rapidity of motion. Thus, because of the lever arms present at the elbow and shoulder, one can move the hand and throw an object at a rate many times faster than the maximal rate of muscle contraction. Ankle Syndesmosis The precise alignment of the tibia and the fibula are important to the function of the ankle joint. A robust ligamentous attachment of the two bones, the ankle syndesmosis is an important stabilizer of the ankle and generally extends at least 4 cm above the joint. Quite frequently, injuries to the tibiotalar joint also disrupt the syndesmosis, causing a splaying or widening of the tibia and fibula. Such injuries generally are managed with a "syndesmotic screw" inserted from lateral to medial, transfixing both fibula and tibia. Ligamentous healing generally is slower than bone healing, and such screws are, therefore, usually

left in place for 8 to 12 weeks. Elective screw removal at that time is common, but the consequence of leaving the screw in place beyond 3 months is screw breakage. The possible morbidity caused by a broken screw in this area is minimal. Acute Rupture of the Achilles Tendon The gastrocsoleus muscle complex acting on the calcaneus through the Achilles tendon can result in very high forces, particularly with sporting activities that involve jumping or rapid changes of direction while running. The Achilles tendon can rupture.6 This is apparent clinically as weakness in plantar flexion. The patient often notes an audible "pop" at the time of injury. Open reconstruction of the tendon is frequently performed, often using augmenting material (cadaver tendon or the autologous plantaris tendon). Operative reconstruction of this tendon does, however, have a significant and troublesome rate of wound complication such as local infection or skin necrosis. Accordingly, many practitioners manage this injury nonoperatively with casting or bracing. Either approach is reasonable.
Brunicardi, FC. (2010). Schwartz's Principles of Surgery (9th ed.). McGraw-Hill