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Running Injuries to the Knee

Stan L. James, MD

Abstract

Approximately one third of serious runners will incur an injury in a given year, Lysholm and Wiklander6 studied
and approximately one third of the injuries will involve the knee. Biomechanical variables in runners’ injuries and
studies on running reveal the tremendous cyclic forces to which the knee is sub- found that a training fault was the
jected. There are several etiologic factors involved, including training errors, cause in 72% of the cases. Such
anatomic and biomechanical variations, and differences in shoes and running sur- training errors involve a sudden
faces. Training errors, particularly rapid transitions in training, are responsible change in the frequency, duration,
for two thirds of injuries. Knee injuries in runners must be approached with a and/or intensity of training. The
thorough review of the training program and a complete examination of the lower most common error is suddenly
extremity. Several conditions can cause anterior knee pain commonly involving increasing mileage or trying to
the extensor mechanism, and these must be differentiated. Most knee injuries can maintain too high a training
be resolved with conservative treatment, but occasionally surgery is indicated. mileage.
After a layoff due to injury or surgery, appropriate rehabilitation, including a Scott and Winter7 calculated the
graduated return to running, is essential to avoid reinjury. patellar tendon force to be around
J Am Acad Orthop Surg 1995;3:309-318 4.7 to 6.9 times body weight. They
also found patellofemoral joint com-
pressive forces to be 7.0 to 11.1 times
body weight in a jogger and two
Distance running is a significant part and Jones3 also found that the knee
middle-distance runners. Peak
of the basic fitness program of many is the most common site of running
loads were associated with the mid-
people. However, “serious” dis- injuries.
support and push-off phases of run-
tance runners (defined as those who
ning, when muscle activity is
run more than 25 miles per week)
maximal. This type of biomechani-
face an injury rate of approximately Biomechanics of Running cal information is consistent with
30% each year. Injuries high knee loads and greater fre-
In their 1985 study, McKenzie et
quency of injury.
al1 reported that the incidence of Leadbetter’s “rule of too’s” (i.e.,
knee injuries in runners had athletes court disaster when they
increased from 18% in studies per- exercise too often, too hard, and too
Dr. James is Courtesy Professor, Department of
formed a few years earlier to 50%. soon and too much after injury and Exercise and Movement Science, University of
They believed that the improved attempt remediation too little and Oregon, Eugene, and is in private practice with
construction of running shoes too late)4 often applies to runner’s Orthopedic & Fracture Clinic of Eugene.
probably played some role in injuries, most of which are attribut-
Reprint requests: Dr. James, Orthopedic & Frac-
reducing the number of leg and able to training errors. The body is
ture Clinic of Eugene, 1200 Hilyard, Suite 600,
foot injuries, but had not been quite a tremendously adaptable mecha- Eugene, OR 97401.
as effective in protecting the knee. nism, but it requires time to accom-
In a review of the epidemiologic lit- modate to new stress levels, which The author or the institutions with which he is
erature in regard to running in the case of the knee can be sig- affiliated have received something of value from a
commercial or other party related directly or indi-
injuries, van Mechelen2 found that nificant. In a study in 1978, James
rectly to the subject of this article.
most running injuries occur in the et al5 reported that training errors
lower extremity, preponderantly in accounted for two thirds of run- Copyright 1995 by the American Academy of
the knee. In another review of data ners’ injuries and that one third of Orthopaedic Surgeons.
on running biomechanics, James the injuries affected the knee.

Vol 3, No 6, November/December 1995 309


Running Injuries to the Knee

Andriacchi et al8 have reported example, is it worse running uphill iliac wings will give some idea of
that the maximum knee-flexion or downhill? Does it vary with the whether there is a leg-length dis-
moment with running is more than intensity of the run? Does the pain crepancy. Extremity length should
five times the moment that normally occur during the swing phase or the be measured from the anterior supe-
occurs during level walking. That support phase? rior iliac spine to the medial malle-
large increase in knee-flexion Previous injuries and their treat- olus. Patellar dynamics should be
moment during the support phase of ment should be investigated because assessed with the patient walking to
running must be balanced primarily there is a tendency toward reinjury detect patellar malalignment or
by the quadriceps mechanism, to a given area. An anecdotal exam- transverse-plane rotational abnor-
which generates significant forces in ple involves a marathon runner with malities. The presence of “squinting
the patellofemoral joint. They also a history of recurrent Achilles prob- patellae” (patellae that incline some-
noted a large adduction moment of lems. As he was telling me his his- what to the midline when the feet
the hip and the knee, which stresses tory, he casually mentioned that are parallel) suggests rotational
the iliotibial band (ITB) and possibly every time his weekly mileage got malalignment. Ankle dorsiflexion
contributes to a very common knee over 80 miles, he seemed to get should be assessed with the knee
injury, ITB friction syndrome. injured. At the time of evaluation, he extended and flexed. At least 10
was running 110 miles per week. It degrees of dorsiflexion is required
was only when I specifically pointed during the support phase of run-
History out what he had just said that he ning; compensatory foot pronation
began to relate mileage to injury. is necessary when there is a tight
Because approximately two thirds4,5 Finally, it is important to identify gastrocsoleus group. The overall
of runners’ injuries are related to the make and style of running shoe alignment and configuration of both
training errors, such as sudden worn and whether a shoe change or feet should be noted with the patient
changes in duration, frequency, or wearing a particular type of shoe can both standing and walking. Muscu-
intensity of training, the single most be related to an injury. If orthotic lar imbalance can often be grossly
important aspect of the history is an devices have ever been used, it is detected with muscle testing against
analysis of the runner’s training pro- helpful to know whether they had resistance.
gram for errors. The examiner must any positive or negative effect on Heel-leg alignment and heel-
be able to “speak the language” of symptoms. forefoot alignment should be evalu-
runners. Noakes’s Lore of Running9 is ated. With the subtalar joint in
perhaps the most comprehensive neutral position, forefoot supina-
resource now available; it covers all Physical Examination tion or pronation is sought. Subta-
aspects of running, including infor- lar joint motion normally should
mation on training as well as physi- The physical examination must allow approximately 8 degrees of
ologic and medical considerations. include a thorough assessment of eversion and 25 degrees of inver-
The runner’s history must the entire lower extremity, from sion (i.e., a ratio of about 1:3). A dis-
include the current complaints, past pelvis to toes. It is not uncommon ruption in this ratio is often
running injuries, running experi- for the cause of knee pain in runners associated with compensatory
ence, training patterns (duration, to be either distal or proximal to the pronation of the foot secondary to
frequency and intensity), and run- knee itself (Fig. 1). One cannot tibia vara, tightness of the gastroc-
ning terrain. Is cross-training used? emphasize enough the importance soleus muscles with limited ankle
What type and how often? Has of not simply concentrating on the dorsiflexion, heel varus, or forefoot
there been a sudden increase in major complaint at the knee without supination. Compensatory prona-
mileage? An increase in miles run a thorough examination of the entire tion becomes necessary for the foot
per week of 10% is about the maxi- lower extremity. It must be borne in to assume a plantigrade position
mum that can be tolerated safely. It mind that gross abnormalities are during the support phase; to
must be kept in mind that many not always present on examination, achieve this, the tibia is held inter-
complaints are secondary to com- nor should they be expected. nally rotated for a longer-than-nor-
pensation for a previous injury that The lower-extremity examina- mal period of time, which, it has
may not, at the time of evaluation, tion should include evaluation of been speculated, creates rotational
be the most prominent problem. It alignment in the frontal and transverse mistiming at the knee.3 Inspection
is important to know where and planes during stance and walking of the runner’s shoes for wear pat-
when the pain occurs in the run. For and/or running. The level of the terns and distortion of the heel

310 Journal of the American Academy of Orthopaedic Surgeons


Stan L. James, MD

ITB
friction
syndrome

Quadriceps
tendinosis Excessive
lateral
Patellar pressure
Excessive instability syndrome
lateral
pressure Plica
syndrome Popliteal
Patellar tenosynovitis
Fibular tendinosis
collateral
Medial collateral Fibular
ligament
ligament collateral
instability
instability ligament
instability Osteoarthritis
Voschel’s
bursitis
Anterior
Pes anserine cruciate
bursitis ligament
instability
Stress
fracture Meniscal lesion

Anterior View Lateral View

Fig. 1 Sites in the knee affected by conditions commonly seen in the runner.

counter may give a clue to the cause Finally, a thorough knee exami- flexion, a tangential view of the
of lower-extremity malalignment. nation must be carried out. Since patella, and a notch view in either
It is not uncommon for runners many of the problems dealing with the weight-bearing or the non-
with knee pain to have several the knee in runners involve anterior weight-bearing position. Such a
anatomic variations. A classic exam- knee pain, the extensor mechanism study is not required for an obvious
ple of such a combination occurs in must be examined in detail, as tendinopathy or other soft-tissue
the “miserable malalignment” described by Fulkerson.10 Patellar condition, but if a degenerative con-
group,5 who usually are seen with position, tracking, stability, and dition, patellofemoral malalign-
the complaint of knee pain associ- crepitus and areas of tenderness ment, or a bone abnormality or
ated with running. Examination about the patella should be noted. injury is suspected, a complete
reveals femoral-neck anteversion examination is certainly warranted.
with a greater range of internal hip
rotation than external hip rotation, Radiographic Examination
genu varum, squinting patellae, Anterior Knee Pain
excessive Q angle, tibia vara, func- Radiographic examination of the
tional equinus with tight gastroc- knee includes at least four views: a Approximately one third of runners’
soleus muscle groups, and often weight-bearing anteroposterior injuries fall into the category of knee
compensatory pronation of the feet. view, a lateral view in 45 degrees of pain (Table 1). In the 1970s, at the

Vol 3, No 6, November/December 1995 311


Running Injuries to the Knee

hands while using the thumbs to Patellar Instability


Table 1 pull up on the lateral patella and Patellar instability is a condition
Causes of Knee Pain in Runners associated with anterior knee pain in
then observing the degree of mobil-
ity present. If the condition has per- runners. A dislocated patella in a
Anterior knee pain sisted, there may be crepitus and runner is rare, but subtle subluxa-
Excessive lateral pressure syn- tion and maltracking are frequent.
tenderness along the lateral patellar
drome
border, which is indicative of possi- Even minor patellar subluxation or
Patellar instability
Quadriceps or patellar ble degenerative changes in the lat- lateral maltracking can alter the nor-
tendinopathy eral-facet articular cartilage. mal distribution of patellofemoral
Pathologic plica An axial view of the patella, such joint-compression forces, creating
Other conditions as the Merchant view (taken with the pain with or without actual articular
Meniscal lesions knee flexed 45 degrees and the x-ray cartilage damage. Usually the pain
Bursitis beam projected caudad at a 30- is insidious and gradual in onset;
Stress fracture degree angle from the femoral however, some dramatic alteration
Osteoarthritis plane), will normally show the in the runner’s program, such as
ITB friction syndrome patella concentrically positioned in incorporating hill workouts, may
Popliteal tenosynovitis trigger pain. Symptoms of giving
the sulcus without tilt or subluxa-
Ligamentous instability
tion. Tilt is suspected when the way may be present, but anterior
medial facet is lifted away from the knee pain is the most common com-
medial trochlear condyle. Since this plaint.
peak of the running boom, the term technique is not particularly sensi- Physical examination to deter-
“runner’s knee” was prevalent in the tive for tilt, there are some instances mine patellar position, tracking, and
lay literature. This term seems syn- in which carefully performed com- stability should be done along with
onymous with chondromalacia in puted tomography should be per- appropriate radiographic evalua-
the professional literature. How- formed, with special emphasis on tion. It is important to observe patel-
ever, neither term accurately defines patellofemoral joint alignment, 10 lar tracking with active knee
the range of problems associated particularly when the diagnosis is extension and flexion. Lateral place-
with anterior knee pain. Several not clearly confirmed and surgery is ment of the patella or lateral
conditions may cause anterior knee contemplated. displacement at termination of
pain and must be specifically diag- Once the diagnosis of excessive extension, termed the J sign, suggests
nosed before any attempt at treat- lateral pressure syndrome has been maltracking. The knee is positioned
ment can be considered. made, a conservative treatment pro- in 30 degrees of flexion, lateral pres-
gram should be initiated (discussed sure is applied to the patella, and the
later in the “Treatment” section). If presence of lateral displacement is
Excessive Lateral Pressure 6 months of conservative treatment noted. Normally, the patella should
Syndrome does not result in reduction of symp- remain secure in the sulcus. A posi-
Excessive lateral pressure syn- toms and the diagnosis is clinically tive instability test, particularly
drome11 is characterized by diffuse and radiographically confirmed, when associated with apprehension,
anterior knee pain, but usually the surgery may be considered denotes instability. A Q angle of
runner will indicate the patella as An arthroscopic or open lateral more than 20 degrees indicates a ten-
being the major site of discomfort. retinacular release is thought to be dency for the quadriceps to displace
Clinical examination of patellar effective for treatment of patellar tilt, the patella laterally. In cases of patel-
tracking may not reveal anything particularly when there is minimal lar instability and maltracking, the
particularly remarkable, but palpa- or no articular involvement of the diagnosis can usually be made on the
tion over the lateral retinaculum patella. A lateral retinacular release basis of the history and clinical exam-
often reveals tenderness. There may when there is no evidence of patellar ination. Confirmation is by x-ray
be tightness of the lateral retinacu- tilt stands much less chance of being examination. Determination of the
lum, which can be identified when successful. Although arthroscopic congruence angle on a Merchant
the lateral border of the patella can- lateral release may seem relatively view of the patella may reveal patel-
not be brought to the horizontal benign, it is important to stress that a lar subluxation. A lateral radiograph
plane on examination. This is deter- rehabilitation period of 8 to 12 weeks with the knee in 30 degrees of flexion
mined by stabilizing the medial may be necessary before the patient will suggest whether there is patella
patella with the fingers of both can return to running. alta, which is often present with

312 Journal of the American Academy of Orthopaedic Surgeons


Stan L. James, MD

instability. The normal ratio of patel- episodes of subluxation or mal- there is a prominent lateral epi-
lar length to patellar-tendon length tracking. condylar ridge or perhaps even an
should be no more than 1:1.2. osteophyte from some degenerative
Most of the more subtle forms of Quadriceps and Patellar patellofemoral joint changes, similar
maltracking and subluxation can be Tendinopathy to that noted with maltracking of the
managed with quadriceps rehabili- Quadriceps tendinosis and patel- patella. Squatting places increased
tation, placing emphasis on closed- lar-tendon (ligament) tendinosis, tension on the tendon and is often
chain exercises. A program directed often referred to as “jumper ’s painful.
by a knowledgeable physical thera- knee,”12 are frequently encountered The tenderness associated with
pist or the physician should be faith- in runners. The latter, by far the patellar tendinosis is best palpated
fully pursued for at least 3 months more common, involves the tendon with the patient’s knee in full exten-
before surgical treatment is even insertion on the distal pole of the sion and the quadriceps relaxed.
considered. Most runners will patella. Excessive stress at the liga- Pressure is applied to the proximal
become symptom-free and can ment insertion on the patella results pole of the patella to tilt the distal
return to training after such a reha- in microruptures and perhaps local pole up, so that the patellar tendon
bilitation program, but continuation areas of deep tendon degeneration insertion may be easily palpated.
of rehabilitation exercises for an or tendinosis. The microtears lead to Occasionally, swelling or induration
indefinite period may be necessary structural deterioration with partial of the soft tissues is also noted. There
even after there has been a return to tissue failure and, in some instances, may be an increased Q angle. The Q
training. can lead to complete rupture of the angle may be observed to change
For the small group of patients for tendon.2 Tendinosis at the tendon dramatically during the support
whom surgical intervention is con- insertion distally on the tibial tuber- phase of gait, during which prona-
sidered, arthroscopic lateral retinac- cle is a far less common running tion or supination of the foot results
ular release followed by patellar injury. in alteration of tibial rotation. This
chondroplasty is the option selected Quadriceps tendinosis is associ- dynamic effect on lower-extremity
most often. A lateral release is com- ated with pain at the insertion site of alignment may aggravate or cause
patible with a return to running and the quadriceps tendon, which is usu- the problem by placing eccentric
is preferable to more extensive pro- ally more lateral than medial, on the traction on the patellar tendon.
cedures. As in the case of patients proximal pole of the patella. Patellar The radiographic findings are
who have had this procedure for lat- tendinosis pain is felt at the distal often normal, although the distal
eral tilt, 8 to 12 weeks of rehabilita- pole of the patella. The runner will pole of the patella may have an elon-
tion is required before a return to usually indicate one or the other area gated or fragmented tip. Occasion-
running. Distally, medial tibial- as the site of maximum discomfort. ally, ectopic bone or calcific deposits
tubercle placement or anteromedial- He or she may also describe local- are noted in the tendon. Ultra-
ization of the tibial tubercle, as ized swelling when the symptoms sonography and magnetic reso-
described by Fulkerson,10 may be are acute, but generally the com- nance (MR) imaging may delineate
indicated. Proximally, medial reti- plaint is largely of pain at the a lesion within the substance of the
nacular reefing can be carried out, involved site, particularly with bent- tendon. These studies are usually
but this must be done judiciously so knee activities. Typically, pain reserved for cases in which conser-
as to avoid creating a tight medial comes on gradually during the vative treatment for at least 3
retinaculum and patellar tilt or rota- course of a run. Initially the symp- months has failed and surgery is
tion. In runners, extensive proximal toms may not stop the runner from contemplated. Ultrasonography is
and distal realignment of the exten- training; with time, however, the quite specific and less expensive
sor mechanism has unpredictable pain becomes more persistent and than MR imaging.
results in terms of the ability to may eventually lead to cessation of Both patellar and quadriceps
return to serious running. The sim- the sport. tendinosis can usually be resolved
pler the procedure, such as a lateral In cases of quadriceps tendinosis, conservatively with the use of the
release, the more likely are the physical examination reveals ten- treatment protocol that will be dis-
prospects for a return to training. In derness directly over the insertion cussed later. Curwin and Stanish13
large part, the result will be deter- site of the quadriceps tendon, which have described an eccentric rehabili-
mined by the extent of patello- is commonly located proximal and tation program for tendinosis with
femoral joint degenerative changes lateral on the patella. There may be a success rate approaching 90%.
or chondral damage from repeated associated crepitus, particularly if However, their results were less suc-

Vol 3, No 6, November/December 1995 313


Running Injuries to the Knee

cessful with patellar tendinosis, with patella and quadriceps tendon. quently the diagnosis can be made
only 30% of patients experiencing Acute knee flexion may elicit supra- on the basis of clinical criteria
relief. patellar pain. An effusion is not alone.
In the event of intractable pain usual; if present, other intra-articu- This condition readily lends itself
that fails to respond to 3 to 6 months lar conditions should be considered. to arthroscopic surgery, generally
of conservative treatment, surgical There is a tendency to overdiagnose with a relatively short interrup-
exploration of the proximal portion this condition, but it is also impor- tion (4 to 6 weeks) in the training-
of the patellar tendon and excision of tant to remember that a truly patho- program. Even so, an appropriate
any abnormal tissue may be consid- logic plica may mimic many other rehabilitation program must be
ered. If the tendinous lesion is quite conditions in the joint. supervised.
large, reattachment of the tendon to The treatment protocol discussed
freshened bone may be necessary. later in this article should be initi- Bursitis
Fortunately, in most patients the ated, but active resistive knee exer- Medial knee pain has been
area of involvement is relatively cises, which may irritate the plica, reported to most commonly involve
small, and the defect can be closed must be avoided. Arthroscopic exci- the pes anserine bursa and Voschel’s
by imbrication. The surgical tech- sion may be necessary in some cases bursa deep to the superficial portion
nique for quadriceps tendinosis is and usually will entail little down- of the medial collateral ligament.15,16
similar. If an osteophyte or promi- time for the runner. If arthroscopic Tenderness with Voschel’s bursitis
nent epicondylar ridge is present, it examination shows that the plica is immediately below the joint line
can be removed to decompress the suspected of causing symptoms is deep to the medial collateral liga-
involved area. not thickened, avascular, and ment. Pes anserine bursitis is more
widened (over 12 mm), Ewing14 sug- distal, with tenderness and perhaps
Pathologic Plica gests that it probably is not the crepitus over the pes anserine area;
Another condition that causes cause of the problem; other causes in addition, active knee flexion
anterior knee pain in runners is should always be diligently sought against resistance may cause pain.
painful plica. Most commonly, a by examining the entire joint. These two conditions must be differ-
medial parapatellar plica becomes entiated from a medial meniscal
fibrotic and rubs or snaps over the lesion, with which there will be ten-
medial femoral condyle with knee Other Conditions derness more directly over the joint
motion. Occasionally, a retained line. Both usually respond promptly
suprapatellar plica may become Meniscal lesions to conservative measures. These
symptomatic as well. Pain usually Meniscal lesions are quite conditions are relatively uncom-
comes on gradually with distance unusual in younger runners but do mon among runners whom I have
running; however, it can be acute become a problem in middle-aged treated.
and associated with a sudden and older runners. The diagnosis of
change in training routine, such as meniscal tears in runners is no dif- Stress Fracture
more intense, shorter-interval work- ferent from that in any other athlete Proximal medial tibial stress frac-
outs. Snapping and buckling may be with this condition. In runners, par- tures are also a consideration but not
noted. The patient may also report ticularly middle-aged and older run- very common in runners. Most tib-
that sitting is painful. Pain may be ners, the onset of pain is usually ial stress fractures occur in the mid-
diffuse, but often the runner can insidious, although there may be an dle and distal thirds of the tibia in
localize it to the medial retinacular inciting incident, such as a misstep runners. They are usually associated
area or the suprapatellar area. or twist. There may be a history of with localized tenderness on palpa-
A common physical finding is joint effusion or catching. Locking tion and swelling. A bone scan is the
localized tenderness over the episodes are less common in the best early diagnostic tool. Once the
femoral condyle adjacent to the older runner. diagnosis has been made, the treat-
medial border of the patella. Often a Physical signs often include a ment is rest until the symptoms
palpable snap and sometimes crepi- small effusion, usually joint-line abate.
tus are noted over a tender and pal- tenderness. In my experience, the
pable medial fibrotic cord. If the McMurray test is positive in about Osteoarthritis
suprapatellar plica is involved, there half of patients. Arthrography or Since running became popular in
may be tenderness and sometimes MR imaging may be helpful if the the 1970s, there has been a signifi-
crepitus on compression of the diagnosis is uncertain, but fre- cant increase in the number of older

314 Journal of the American Academy of Orthopaedic Surgeons


Stan L. James, MD

runners. It is not unusual to find downhill. The pain is lateral, often sound with topical hydrocortisone)
very dedicated runners in the sixth starts a mile or two into the run, in the area of involvement may help
and seventh decades of life. With becomes worse for the duration of resolve the condition, particularly in
increasing age, the frequency of the run, and may cease on stopping. the acute phase. Other techniques
osteoarthritic conditions increases, Sometimes it occurs only with include stretching the ITB and
although there is no evidence to date downhill running and running on strengthening the abductor muscu-
in the literature that implicates run- the level; participation in other lature.
ning as a cause of degenerative sports is pain free. Surgery may be indicated in
changes in a normal knee.17 Once The physical findings are tender- patients with intractable symptoms.
degenerative changes are estab- ness over the distal ITB and the lat- Before arthroscopy of the joint is
lished, the running program must eral femoral condylar region, with performed, the knee must be care-
be carefully customized and moni- occasional swelling and sometimes fully inspected, particularly the lat-
tored. crepitus. The lateral condyle may be eral compartment, to rule out a
A frequent question from runners prominent. The runner frequently meniscal lesion or other disorder,
is whether running will accelerate a has genu varum and/or tibia vara, such as synovitis or pathologic lat-
known osteoarthritic condition. The heel varus, forefoot supination, and eral plica. If no other cause is iden-
answer is yes, it probably does to compensatory pronation. Examina- tified, an open procedure similar to
some extent, depending on the tion of the running shoes often that described by Noble18 is per-
program. This possibility raises a shows excessive lateral heel wear. formed to release the posterior 2 cm
difficult problem for runners. Some- This combination of subtle lower- of the ITB at the level of the lateral
times it is best to first allow them to extremity malalignments is thought condyle, where it appears to create
try to find a program that their knees to cause increased friction between the most tension over the femoral
will tolerate. If they are unable to do the ITB and the lateral femoral condyle. This procedure has been
so, it may be easier for them to make condyle due to greater tension on effective in my experience and usu-
the decision to discontinue running the lateral structures. It is also ally allows a return to running
rather than being arbitrarily told thought that hip abductor weakness within 4 weeks. However, as is the
they must stop. With significant with early muscle fatigue may cause case for many operations used in the
degenerative changes, alternative exaggerated pelvic sag during the treatment of runners’ injuries, there
low-impact aerobic activities are an support phase and place increasing are no well-controlled prospective
option; these include cross-country tension on the ITB. This enhances clinical studies that unequivocally
skiing or using ski machines, swim- friction between the ITB and the lat- show efficacy.
ming, doing aerobic water exercis- eral femoral condyle, which results
es, biking, and race-walking. in synovitis. Tenderness is typically Popliteal Tenosynovitis
Minimal joint debridement with present about 2 to 3 cm proximal to Popliteal tenosynovitis also
arthroscopic removal of sympto- the joint line and over the lateral causes lateral knee pain but in my
matic osteophytes, degenerative femoral condyle and distal portion practice is not as frequent as ITB fric-
menisci, and loose bodies may help of the ITB. tion syndrome. It involves the
symptomatically, but whether this Ober’s test may be positive for popliteal tendon posterolaterally
results in long-term improvement is ITB tightness. However, a better test and may vary from a transient con-
debatable. Extensive chondroplas- is performed as follows: With the dition to one that becomes chronic.
ty procedures and abrasion chon- patient lying on his or her side with The onset is often associated with
droplasty procedures are not very the affected knee up, pressure is downhill running.
effective in allowing a return to run- applied to the lateral femoral Examination reveals tenderness
ning. condyle. The knee is then moved directly over the popliteal tendon
through a range of motion of about just posterior to the fibular collateral
Iliotibial Band Friction 30 to 45 degrees. This positions the ligament. It sometimes is difficult to
Syndrome tensed ITB directly over the lateral differentiate this condition from ITB
Iliotibial band friction syndrome9 femoral condyle, which accentuates friction syndrome or a lateral menis-
is the most common problem pain. cal lesion. The former can be differ-
involving the lateral aspect of the In addition to the modalities usu- entiated because tenderness is
knee in runners. It is usually initi- ally used in the treatment of runners’ located over the ITB at the femoral
ated by an extra-long run and is par- injuries in general, a corticosteroid condyle; in the latter, tenderness is
ticularly aggravated by running injection or phonophoresis (ultra- directly over the lateral joint line.

Vol 3, No 6, November/December 1995 315


Running Injuries to the Knee

Treatment is conservative and motion for compensatory pronation.


similar to that used for ITB friction Table 2 The support shoe is for the individ-
Treatment Considerations
syndrome. I have never considered ual who does not demand much con-
it necessary to operate on a patient trol. A cushion shoe is for the runner
with this condition. Training program with a rigid-type foot requiring
Anatomic and biomechanical
more flexibility and cushioning for
variations
Ligamentous Instability shock absorption. Usually an ortho-
Shoe modifications
Ligamentous instability of the Muscle reconditioning and tist or shoe-repair shop can modify
knee is not a common injury caused flexibility running shoes for special problems,
by running, even among com- Orthotic devices such as leg-length discrepancies.
petitive runners. However, some Medications and physical therapy Changing the hardness of the mid-
recreational runners may have liga- Surgery sole and heel wedge and using a
mentous instability, particularly Rehabilitation variable-hardness heel wedge can
anterior cruciate ligament deficits, change foot mechanics by altering
which have been incurred in other pronation or supination, which then
sports. If the menisci remain intact, influences knee function through the
there are no recurrent episodes of amount of obligatory tibial rotation
instability with swelling and pain, They generally prefer modification during pronation. However, heel-
and the activity of running is con- of the program by reducing the fre- wedge and midsole cushioning do
fined to good surfaces, the knee quency, intensity, and duration of little to alter the vertical impact
may function well without difficulty. their running. Running in water forces during the support phase.
(aqua-jogging) is an excellent form
of non-weight-bearing cross-train- Muscle Reconditioning and
Treatment ing for running during rehabilita- Flexibility
tion, which allows patients to Restoring the muscle strength,
Most knee injuries in runners can maintain a high level of aerobic con- endurance, and balance of the entire
be resolved with the use of conserv- ditioning as well as lower-extremity lower extremity is essential after
ative methods.19 Nigg20 suggests that muscle strength and endurance and injury. If runners do not specifically
the most effective biomechanical joint mobility. restore muscle strength and
strategies to reduce load and stress endurance to affected muscle
on a locomotor system involve the Anatomic and Biomechanical groups, deficits will persist even
following factors: (1) the movement, Variations after they return to running. Gentle,
such as a change in running style; Thorough assessment of the sustained stretching is another
(2) the surface (i.e., soft versus hard); entire lower extremity is mandatory. aspect of conditioning that must not
(3) the shoe (current shoe designs As stressed earlier, concentrating on be ignored, since tightness of the
provide variability in cushion effect the site of the injury about the knee hamstring and gastrocsoleus muscle
and motion control of the foot); and will often lead the examiner to over- groups is very common among dis-
(4) the frequency of repetitive move- look the etiologic factor actually tance runners.
ments (e.g., the mileage, pace, or causing the pain. Thus, it is impor-
duration of running). tant to look both distal and proximal Orthotic Devices
A logical treatment protocol that to the knee for anatomic or biome- By controlling pronation and
addresses the elements listed in chanical variations. It is also impor- supination, orthotic devices are used
Table 2 is adaptable for virtually all tant to learn how to evaluate foot to alter foot biomechanics. The pur-
runner’s injuries, including those function.3,5,21 pose of an orthotic device in the shoe
involving the knee. is to allow the subtalar joint complex
Shoe Modifications to function effectively from the neu-
Training Program Shoes generally come in three tral position during the support
The training program must first classifications: motion control, sup- phase, reducing the amount and
be evaluated and modified as neces- port, and cushion. Most running- duration of compensatory prona-
sary. This will often resolve many of shoe manufacturers have shoes tion. The special materials used to
the injuries. Rest is the last bit of fitting these classifications. A fabricate the devices provide func-
advice runners generally want to motion-control shoe is for someone tional and impact shock absorp-
hear, but at times it is necessary. who needs control of subtalar joint tion.9,21,22 These devices are most

316 Journal of the American Academy of Orthopaedic Surgeons


Stan L. James, MD

useful in the treatment of problems minate running in spite of well-indi-


due to subtle patellar maltracking or cated surgery. Table 3
Program for Graduated Return to
the ITB friction syndrome.
Running
Rehabilitation
Medications and Physical If surgery has been deemed neces-
Week Activity
Therapy sary, the surgeon must direct the post-
Reducing pain and inflammation operative rehabilitation program with
1 Walk 4 to 8 laps (alternate
with medications such as non- the athlete, the trainer or physical ther- 50 m fast, 50 m normal)
steroidal anti-inflammatory agents apist, and the coach. All too often, the
is helpful. Physical therapy modali- results of surgery are negated by too 2 Walk 8 to 12 laps (alter-
ties are also options. Corticosteroid rapid a return to running without ade- nate 100 m fast, 100 m
injection is generally contraindi- quate and careful rehabilitation. A normal)
cated in tendons. The most likely program that I have found quite satis-
indications for steroid injection are factory (Table 3), with modification 3 Jog 10 minutes every
ITB friction syndrome, popliteal depending on the individual situa- other day at an easy
tenosynovitis, and bursitis, par- tion, emphasizes a graduated return pace
ticularly in the acute phase. Admin- to running after a layoff from injury or
4 Jog 15 minutes every
istering narcotic analgesics or surgery. The patient should use an
other day
injecting local anesthetics to allow easy, comfortable pace (7 to 10 min-
running cannot be condoned. utes per mile). He or she should also 5 Jog 15 minutes one day,
rest one day each week and not be 25 minutes the next
Surgery concerned about mileage or aerobic
Most runner’s injuries can be conditioning. The purpose of the pro- 6 Jog 20 minutes one day,
managed conservatively, but the gram is to condition the injured area. 30 minutes the next
program must be adequately super- During the course of the graduated
vised so that if conservative means buildup, the patient can hold at a 7 Jog 20 minutes one day,
fail, the runner, the coach, and the given level or even drop back a level if 35 minutes the next
physician will feel comfortable necessary. Aerobic conditioning can
8 Jog 20 minutes one day,
about considering surgical treat- be maintained with cross-training
40 minutes the next
ment if indicated. activities, such as aqua-jogging, swim-
Surgery is not often required in ming, and biking. General strength- 9 Resume training at an
runners, and the indications for ening and flexibility exercises should appropriate mileage
surgery are really no different from also be used. and intensity
those in the general population.
Surgery is reserved as almost a last
resort, particularly in the elite run- Summary
ner, except in the presence of certain sive history of the training program,
conditions that can be managed The knee remains the primary loca- a thorough examination of the entire
effectively with early arthroscopic tion for lower-extremity injuries in lower extremity (not just the knee),
surgery, such as a documented runners, being the site of approxi- and a methodical approach to treat-
meniscal lesion or loose body. This mately 30% of all injuries. Anterior ment are essential. Most problems
does not necessarily mean unusual knee pain is the most common knee can be resolved conservatively, but
or unwarranted delay, but rather complaint. Although many factors surgery is occasionally indicated.
taking a methodical approach to the are involved, training errors, particu- After an injury or surgery to the
problem. In some situations, it is larly rapid transitions in the program knee, the physician must supervise
important to point out to the runner and increases in mileage, are the pri- the rehabilitation and the return to
that the condition could actually ter- mary cause of injury. A comprehen- running so as to avoid reinjury.

Vol 3, No 6, November/December 1995 317


Running Injuries to the Knee

References
1. McKenzie DC, Clement DB, Taunton JE: 8. Andriacchi TP, Kramer GM, Landon Thorofare, NJ: Charles B. Slack, 1982,
Running shoes, orthotics, and injuries. GC: The biomechanics of running and pp 55-75.
Sports Med 1985;2:334-347. knee injuries, in Finerman G (ed): 16. Rubin BD, Collins HR: Runner’s knee.
2. van Mechelen W: Running injuries: A American Academy of Orthopaedic Sur- Phys Sports Med 1980;8:47-58.
review of the epidemiological literature. geons Symposium on Sports Medicine: 17. Lane NE, Michel B, Bjorkengren A, et al:
Sports Med 1992;14:320-335. The Knee. St Louis: CV Mosby, 1985, The risk of osteoarthritis with running
3. James SL, Jones DC: Biomechanical pp 23-32. and aging: A 5-year longitudinal study.
aspects of distance running injuries, in 9. Noakes T: Lore of Running, 3rd ed. J Rheumatol 1993;20:461-468.
Cavanagh PR (ed): Biomechanics of Dis- Champaign, Ill: Leisure Press, 1991. 18. Noble CA: The treatment of iliotibial
tance Running. Champaign, Ill: Human 10. Fulkerson JP: Patellofemoral pain dis- band friction syndrome. Br J Sports
Kinetics Books, 1990, pp 249-269. orders: Evaluation and management. J Med 1979;13:51-54.
4. Leadbetter WB: Aging effects upon the Am Acad Orthop Surg 1994;2:124-132. 19. Taunton JE, Clement DB, Smart GW,
repair and healing of athletic injury, in 11. Ficat RP, Hungerford DS: Disorders of et al: Non-surgical management of
Gordon SL, Gonzalez-Mestre X, Garrett the Patello-femoral Joint. Baltimore: overuse knee injuries in runners. Can J
WE Jr (eds): Sports and Exercise in Williams & Wilkins, 1977, pp 123-148. Sport Sci 1987;12:11-18.
Midlife. Rosemont, Ill: American Acad- 12. Blazina ME, Kerlan RK, Jobe FW, et al: 20. Nigg BM: Biomechanics, load analysis
emy of Orthopaedic Surgeons, 1993, pp Jumper’s knee. Orthop Clin North Am and sports injuries in the lower extrem-
177-223. 1973;4:665-678. ities. Sports Med 1985;2:367-379.
5. James SL, Bates BT, Osternig LR: 13. Curwin S, Stanish WD: Tendinitis: Its 21. D’Ambrosia RD, Douglas R: Orthotics,
Injuries to runners. Am J Sports Med Etiology and Treatment. Lexington, Mass: in D’Ambrosia R, Drez D Jr (eds): Pre-
1978;6:40-50. Collamore Press, 1984, pp 162-163. vention and Treatment of Running Injuries.
6. Lysholm J, Wiklander J: Injuries in run- 14. Ewing JW: Plica: Pathologic or not? J Thorofare, NJ: Charles B. Slack, 1982,
ners. Am J Sports Med 1987;15:168-171. Am Acad Orthop Surg 1993;1:117-121. pp 155-164.
7. Scott SH, Winter DA: Internal forces of 15. Leach R: Running injuries of the knee, 22. Mann RA, Baxter DE, Lutter LD: Run-
chronic running injury sites. Med Sci in D’Ambrosia R, Drez D Jr (eds): Pre- ning symposium. Foot Ankle 1981;1:190-
Sports Exerc 1990;22:357-369. vention and Treatment of Running Injuries. 224.

318 Journal of the American Academy of Orthopaedic Surgeons


Scapular Winging

John E. Kuhn, MD, Kevin D. Plancher, MD, and Richard J. Hawkins, MD, FRCS(C)

Abstract
Scapular winging, one of the more common scapulothoracic disorders, is caused (including surgical biopsy of lymph
by a number of pathologic conditions. It can be classified as primary, secondary, nodes in the posterior cervical trian-
or voluntary. Primary scapular winging may be due to neurologic injury, patho- gle3,4 and radical neck dissection).1
logic changes in the bone, or periscapular soft-tissue abnormalities. Secondary After injury to the spinal acces-
scapular winging occurs as a result of glenohumeral and subacromial conditions sory nerve, the patient assumes a
and resolves after the primary pathologic condition has been addressed. Volun- position with the shoulder depressed
tary scapular winging is not caused by an anatomic disorder and may be associ- and the scapula translated laterally
ated with underlying psychological issues. The evaluation and treatment of these with the inferior angle rotated later-
three types are discussed. ally (Fig. 1, A). Patients will attempt
J Am Acad Orthop Surg 1995;3:319-325 to compensate for this deformity by
using muscles of the shoulder girdle,
including the levator scapulae and
the rhomboids. This strain may lead
Scapular winging is one of the most smooth rhythm may become evident to disabling pain and muscle spasm.5
common abnormalities of the scapu- with dynamic testing. The examiner Patients can also have pain due to
lothoracic articulation. Winging may must also look for winging with secondary effects of winging, includ-
be described as primary, secondary, resisted motion, such as may occur ing adhesive capsulitis, subacromial
or voluntary (Table 1). Primary when the patient pushes against a impingement, and radiculitis from
scapular winging is caused by wall or resists forward elevation traction on the brachial plexus. On
anatomic disorders that directly affect with the arms at 30, 90, and 150 examination, patients will have
the scapulothoracic articulation. Sec- degrees. Static, dynamic, or resisted trapezius wasting, will be unable to
ondary scapular winging usually winging may be graded subjectively shrug the shoulder, and will have
accompanies some glenohumeral dis- as mild, moderate, or severe. associated weakness on forward ele-
order and should resolve once that
disorder has been addressed. Volun-
tary winging may have psychological Primary Scapular Winging
Dr. Kuhn is Lecturer, Division of Sports Medi-
overtones and is quite rare.
cine, Section of Orthopaedic Surgery, University
Neurologic Origin of Michigan Medical Center, Ann Arbor. Dr.
Plancher is Assistant Professor, Albert Einstein
Evaluation Trapezius Winging College of Medicine, New York; Attending Sur-
The spinal accessory nerve, which geon, Montefiore Medical Center, New York; and
Hand Consultant, Steadman-Hawkins Clinic,
Patients with scapular winging provides the only innervation to the
Vail, Colo. Dr. Hawkins is Clinical Professor,
should be first observed at rest with trapezius muscle,1 is located in the Department of Orthopedics, University of Col-
the arms at the sides. A static defor- subcutaneous tissue on the floor of orado Medical School, Denver, and Orthopaedic
mity should be sought, as well as the posterior cervical triangle. Its Consultant, Steadman-Hawkins Clinic, Vail.
muscle atrophy. The patient is then superficial location makes it suscep- Reprint requests: Dr. Kuhn, The University of
asked to elevate his arms in the for- tible to injury, which can result in Michigan Shoulder Group, 24 Frank Lloyd
ward plane, and the scapulae are significant deformity as well as Wright Drive, Box 363, Ann Arbor, MI 48106-
observed in relation to the chest painfully disabling alterations in 0363.
wall. The scapulothoracic rhythm scapulothoracic function.2-4 Injury Copyright 1995 by the American Academy of
and the presence of crepitus should can be caused by blunt trauma,4,5 Orthopaedic Surgeons.
be noted; alterations in the normally traction,4 or penetrating trauma

Vol 3, No 6, November/December 1995 319


Scapular Winging

are unlikely to benefit from contin- scapulae substitutes for the upper third of
Table 1 ued conservative treatment, and the trapezius; the rhomboideus major,
Classification of Scapular surgery can be offered. Historically, for the middle third; and the rhom-
Winging a variety of surgical procedures have boideus minor, for the lower third. By
been described for the treatment of moving these muscle insertions laterally,
Primary
spinal accessory nerve paralysis.2,9,10 their mechanical advantage is improved,
Neurologic origin
These can be divided into static and and winging is diminished or eliminated.
Spinal accessory nerve
(trapezius palsy) dynamic procedures. Static stabiliza- The surgical technique involves
Long thoracic nerve tion includes scapulothoracic fusion9 two incisions. The first is along the
(serratus anterior palsy) and any of the many operations that medial scapular border, and the sec-
Dorsal scapular nerve tether the scapula to the spine.2 The ond is over the spine of the scapula.
(rhomboideus palsy) dynamic procedures all involve some The levator scapulae, rhomboideus
Osseous origin form of muscle transfer.5,10,11 Because minor, and rhomboideus major are
Osteochondromas scapulothoracic fusions represent a detached from their origins, taking a
Fracture malunions huge undertaking and may limit small portion of insertional bone
Soft-tissue origin motion significantly, and because fas- from the medial scapula. The rhom-
Contractural winging
cial-sling suspensions tend to fail, boid muscles are advanced laterally
Muscle avulsion or agenesis
causing recurrence of winging in 2 to under the infraspinatus and are
Scapulothoracic bursitis
Secondary 3 years,5 dynamic muscle transfers secured with suture, which is passed
Voluntary have become the procedure of choice through drill holes placed 5 cm lateral
for persistent trapezius winging.5,10-13 to the medial border of the scapula.
The muscle-transfer operation per- The levator scapulae is passed 5 cm
haps most commonly performed for laterally, subcutaneous to the second
vation and abduction of the arm. The trapezius paralysis is the Eden-Lange incision, and is sutured to the scapu-
diagnosis can be confirmed by elec- procedure,5,12,13 in which the levator lar spine through drill holes. Postop-
tromyographic (EMG) examination. scapulae, rhomboideus minor, and eratively, a sling is used for 6 weeks,
Treatment depends on the dura- rhomboideus major muscles are trans- after which passive and then active
tion and severity of symptoms. An ferred laterally (Fig. 2). The levator range-of-motion exercises are used.
initial treatment regimen including
physical therapy is helpful to main-
tain glenohumeral motion and pre-
vent adhesive capsulitis. In patients
in whom spinal accessory nerve
injury is due to blunt trauma, serial
EMG examinations may be per-
formed at 6-week intervals to follow
the returning function of the nerve.
This is usually not begun until 3
months after the injury, because
denervation changes in the muscle
may not be manifest before that
time. In nerve injuries due to pene-
trating trauma, or when there is no
evidence of nerve function on EMG
analysis, neurolysis and/or nerve
grafting can be considered.3,6-8 The
results of these procedures have
been variable. If neurolysis is per-
formed, the success rate seems to be
improved if the procedure is done A B
within 6 months of the injury.5 Fig. 1 Position of the scapula with primary scapular winging due to trapezius palsy (A) and
Patients who have had debilitat- serratus anterior palsy (B).
ing symptoms for more than 1 year

320 Journal of the American Academy of Orthopaedic Surgeons


John E. Kuhn, MD, et al

nerve originates from the ventral degrees, which will magnify the
rami of the C5, C6, and C7 cervical degree of winging. Pain may be
nerves and travels beneath the increased with this maneuver and
brachial plexus and clavicle over the when the head is tilted toward the
first rib. The nerve then travels along contralateral shoulder.
the lateral aspect of the chest wall Electromyography is recom-
superficially, making it susceptible mended to confirm the diagnosis.
to injury. Blunt trauma or stretching Electromyographic examinations at
of this nerve is particularly common 3-month intervals have also been
in athletes and has been reported in recommended to follow nerve
almost every sport.14-16 Repetitive recovery.22,24
industrial use of the shoulder has Range-of-motion exercises to
also been implicated as a cause of ser- prevent adhesive capsulitis of the
ratus anterior paralysis.17 Penetrat- shoulder should be implemented
ing trauma will rarely cause injury to immediately on diagnosis. Many
this nerve, although surgical proce- types of braces and orthotic devices
dures such as radical mastectomy, have been developed.20 They may
first-rib resection, axillary lymph- have some role, but often their cum-
node dissection, and transaxillary bersome nature overshadows symp-
sympathectomy have been impli- tom relief.22 Most injuries of the long
cated as sources of injury to the long thoracic nerve recover sponta-
thoracic nerve.16 neously within 1 year,15,17,20,22,25 but
The long thoracic nerve can also recovery may take up to 2 years.26
be affected by nontraumatic events, There is little data in the literature
including positioning during anes- regarding the results of neurolysis,
thesia,17 the sequelae of viral ill- nerve grafting, or nerve repair of an
ness,18 inoculations,19 and neuritis injured long thoracic nerve. Never-
Fig. 2 Eden-Lange dynamic transfer, used affecting the brachial plexus or the theless, penetrating injuries should
to treat trapezius paralysis.5 The levator be treated with nerve exploration
scapulae, rhomboideus minor, and rhom-
long thoracic nerve alone.20,21 Even
boideus major muscles are detached from prolonged bed rest has been and early repair. Neurorrhaphy may
their origins (inset), taking a small portion of reported to trigger dysfunction of be indicated when the lesion can be
insertional bone from the medial scapula. localized.22 Patients with persistent
The rhomboid muscles are advanced later-
the long thoracic nerve, particularly
ally under the infraspinatus and are secured if the arm is abducted while prop- impairment of the serratus anterior
with suture, which is passed through drill ping up the head to read.17,22 Since are often able to compensate, and
holes placed 5 cm lateral to the medial bor- most do not require surgical recon-
der of the scapula. The levator scapulae is
the long thoracic nerve has its ori-
passed 5 cm laterally and is sutured to the gin at C7, patients with C7 radicu- struction.22 For patients who have
scapular spine through drill holes. lopathy may also manifest serratus had symptomatic serratus winging
anterior weakness and scapular for more than 1 year and whose
winging.23 EMG studies show total denerva-
With an injury to the long thoracic tion, surgical options may be offered
Bigliani et al5 recently reported nerve, the scapula assumes a posi- to alleviate pain and improve func-
their results with this procedure. tion of superior elevation and tion.
Of 23 patients with trapezius wing- medial translation, and the inferior Like the surgical treatments for
ing, 87% had good or excellent pole is rotated medially (Fig. 1, B). trapezius winging, the operations for
results. Significant improvement in Patients will complain of pain as the serratus paralysis can be classified
pain was seen in 91% of these other periscapular muscles try to into three types: scapulothoracic
patients, and 87% demonstrated an compensate for the serratus weak- fusions,9 fascial sling suspensions,7
improvement in function. ness. More severe pain may indicate and muscle transfers. A variety of
acute brachial plexus neuritis or Par- muscle-transfer operations have
Serratus Anterior Winging sonage-Turner syndrome, which been described; these include the use
Palsy of the serratus anterior mus- may affect the long thoracic nerve of the pectoralis minor, the pec-
cle can also cause painful, disabling alone.21 The patient will have diffi- toralis major, the sternocostal head
scapular winging. The long thoracic culty with arm elevation above 120 of pectoralis major, the clavicular

Vol 3, No 6, November/December 1995 321


Scapular Winging

head of the pectoralis major, the


teres major, the rhomboid muscles,
and combinations of these muscles.
Scapulothoracic fusions for serra-
tus winging have been discouraged
by some,20 primarily because of the
associated inherent loss of motion,
as well as the magnitude of the
surgery. Pain relief, however, is a
reasonable expectation.9 Complica-
tions of scapulothoracic fusions are
many and include nonunion and
pneumothorax.9 For these reasons,
as well as the limited expectations
with regard to motion, scapulotho- B
racic fusions have been generally A
reserved for salvage operations after
failure of other techniques and for
treating patients with paralysis of
other shoulder girdle muscles in
addition to the serratus anterior.24
Although controversial, a primary
scapulothoracic fusion may also be
considered for the laborer with
disabling serratus winging who
places heavy demands on the
shoulder.26
Fascial-sling suspensions to cor-
rect serratus winging have been
advocated by some.7,27 However,
there are significant concerns about
sling failure and recurrence of wing- C
ing.10 For these reasons, muscle
D
transfers for dynamic scapular stabi-
lization have gained broader accep-
Fig. 3 Marmor-Bechtol transfer of the ster-
tance. nocostal head of the pectoralis major, used
Of the variety of muscle transfers to treat serratus anterior paralysis.28 A, With
that have been described, transfer of the patient in the lateral decubitus position,
an incision is made, crossing the axilla from
the sternocostal head of the pec- the pectoralis major muscle anteriorly to the
toralis major with a fascia lata graft inferior tip of the scapula. B, The ster-
extension28 (Fig. 3) is probably the nocostal head of the pectoralis major is
released from its insertion on the bicipital
most popular.22,24,25,29 In this tech- groove of the humerus, leaving the clavicu-
nique,24,28,29 the patient is placed in lar head intact. C, A graft of fascia lata mea-
the lateral decubitus position with suring 7 by 2 inches is harvested from the
ipsilateral leg and sutured into a 7-inch-long
use of a beanbag, and the involved tube. Graft is then sutured to the distal por-
arm and forequarter are prepared tion of the freed pectoralis tendon. D, A
and draped. An incision is made, foramen is made in the inferior angle of the
scapula. E, The graft is inserted through this
crossing the axilla from the pectoralis foramen and sutured to itself under moder-
major muscle anteriorly to the infe- ate tension.
rior tip of the scapula. The ster-
nocostal head of the pectoralis major E
is released from its insertion on the
bicipital groove of the humerus,

322 Journal of the American Academy of Orthopaedic Surgeons


John E. Kuhn, MD, et al

leaving the clavicular head intact. A and laterally by the unopposed ser- Because muscle function is not
graft of fascia lata measuring 7 by 2 ratus anterior muscle.27 With weak- impaired, affected patients may not
inches is harvested from the ipsilat- ness of the rhomboid muscles, the be symptomatic.
eral leg and sutured into a 7-inch- winging is accentuated when the
long tube. This graft is then sutured arm is slowly lowered from the for- Muscular Origin
to the distal portion of the freed pec- ward elevated position. The inferior Muscle abnormalities that cause
toralis tendon. After the inferior bor- angle of the scapula is pulled later- winging include traumatic ruptures
der of the scapula has been exposed, ally and dorsally.30 The patient will and congenital absence of periscapu-
a foramen is made in the inferior also have difficulty pushing the lar muscles. In patients with serra-
angle. The graft is inserted through elbow backward against resistance tus anterior muscle avulsion,
this defect and sutured to itself under with the hands on the hips. significant trauma has occurred,
moderate tension. Postoperatively, Treatment of rhomboideus wing- which pulls the muscle insertion
the arm is placed in a sling, and pas- ing consists of trapezius-strength- from the medial border of the
sive motion is started after 4 weeks. ening exercises. Although no scapula.17,32-34 Fiddian and King 14
Active motion is begun at 6 weeks muscle-transfer operations have reported the case of a patient in
and strengthening at 12 weeks. been described for rhomboideus whom serratus anterior division
Although there are few large series in palsy, the patient with significant occurred during thoracotomy,
the literature, results with this tech- symptoms for whom conservative which produced symptomatic wing-
nique have been encouraging, with therapy has proved a failure may be ing. In this situation, early nerve-
70% to 91% success rates, defined on helped by a fascial-sling operation, conduction studies may be normal,
the basis of normal shoulder motion as described by Dickson.7,27 In this and magnetic resonance imaging
and a significant reduction in pain operation, two fascia lata grafts are should be considered to assist in the
and winging.16,24,25,29 tubularized and used to connect the diagnosis. Surgical reattachment is
lower vertebral border of the recommended in all cases, and excel-
Rhomboideus Major and Rhomboideus scapula to the spinal muscles and the lent results can be expected.17,32,34
Minor Winging inferior angle of the scapula to the However, the combination of ad-
Weakness of the greater and fibers of the latissimus dorsi. This vanced age and systemic disease
lesser rhomboid muscles is a rare procedure is thought to be useful in may be a contraindication to sur-
source of scapular winging. These stabilizing the scapula and partially gery.33
muscles are innervated by the dorsal arresting the high thoracic scoliosis Congenital absence of the serra-
scapular nerve, which takes its ori- that may occur with rhomboideus tus anterior,35 the trapezius,36 and
gin from the C5 nerve root. The dor- and levator scapulae paralysis.27 the rhomboideus major and trapez-
sal scapular nerve passes deep to or, ius muscles36 have all been reported
in some patients, through the levator Osseous Origin as causes of scapular winging.
scapulae on its way to the rhomboid Osteochondromas, the most Patients with these congenital anom-
muscles. A C5 radiculopathy or an common scapular tumors, can be a alies seem to function very well
injury to the dorsal scapular nerve cause of “pseudowinging.”14 Rib osteo- without treatment.36
may produce rhomboid weakness chondromas may also cause the
and scapular winging.30 Patients deformity.14 This type of winging is Bursal Origin
may complain of pain along the structural and may be associated The articulation between the
medial border of the scapula. The with scapular crepitus. The winging scapula and the thorax is character-
winging produced by rhomboideus may not change when the position ized by bursae, which in rare cir-
palsy at rest is usually minimal but of the arm is varied. The EMG find- cumstances may become inflamed,
may appear similar to trapezius ings will be normal in patients with causing scapular crepitus and pain.
winging, with the shoulder slightly such osteochondromas; however, In one study,37 winging was identi-
depressed, the scapula laterally the lesion can be identified on radio- fied in 50% of patients with a symp-
translated, and the inferior angle graphs obtained tangential to the tomatic snapping scapula and no
rotated laterally. plane of the scapula or on computed bone abnormalities. This type of
On physical examination, atro- tomograms. Winging is alleviated winging is presumably related to
phy may be evident along the with resection of the abnormal bone. subscapular bursitis. With treat-
medial border of the scapula. Dur- Malunions of scapular fractures ment of the bursitis, either by
ing arm elevation, the inferior angle have also been implicated as a nonoperative means or surgical bur-
of the scapula is pulled downward source of primary winging. 31 sectomy, the winging resolves.

Vol 3, No 6, November/December 1995 323


Scapular Winging

Asymptomatic scapulothoracic muscle is thought to be either con- to improve until the primary prob-
crepitus also exists but is usually not genital41 or related to a history of lem is addressed.38 Nevertheless, in
associated with scapular winging. injections,42 and is almost always every patient with secondary scapu-
associated with scapular winging.42 lar winging, a scapular rehabilita-
Common disorders involving the tion program should be added to the
Secondary Scapular glenohumeral joint can also be a treatment of the primary gleno-
Winging cause of secondary scapular winging. humeral disorder to facilitate re-
The mechanism is thought to be due covery.
Secondary scapular winging orig- to reflex muscle spasm provoked by
inates from disorders of the some painful condition in the gleno-
glenohumeral joint that produce humeral or subacromial area. 40 Voluntary Scapular
abnormal scapulothoracic dynam- Winging has been associated with Winging
ics. This phenomenon has not been rotator cuff tears,40 nonunion of
thoroughly investigated in the pub- acromion fractures,15 malunion of Voluntary scapular winging is very
lished literature. clavicular fractures,14 fractures of the rare.14,15,38,43 In fact, the largest series
A thorough evaluation of the glenoid, 14 osteonecrosis of the is Rowe’s report of four cases.43 The
patient with secondary scapular humeral head, 15 acromegalic ar- patients were reassured and in-
winging will usually, but not always, thropathy of the shoulder,14 acromio- structed on the normal muscle-firing
identify the source as a glenohumeral clavicular joint disorders,14,38 and patterns of the shoulder, with
or subacromial disorder.38 When shoulder instability.14,38 In our prac- “instructions not to tighten or con-
examining any patient with a shoul- tice, we have observed secondary tract their shoulder muscles when
der condition, secondary scapular scapular winging in patients with elevating the arm.” All four recov-
winging should be sought with the adhesive capsulitis, the impingement ered after this coaching. In another
shoulder at rest, with dynamic for- syndrome, anterior shoulder instabil- report, Gregg et al15 described
ward elevation, and with resisted for- ity, posterior shoulder instability, asymptomatic bilateral voluntary
ward elevation. One would expect a and multidirectional shoulder insta- scapular winging in an orthopaedic
patient with secondary scapular bility. We have also encountered sec- resident. It is important to appreciate
winging to have normal findings on ondary impingement due to subtle that patients with voluntary scapular
EMG and nerve-conduction exami- shoulder instability in throwing ath- winging who seek medical attention,
nations of the long thoracic nerve and letes. like patients with voluntary subluxa-
serratus anterior muscle, the spinal Winging frequently accompanies tion of the shoulder, may have unad-
accessory nerve and trapezius mus- the asynchronous shoulder motion dressed psychological issues that
cle, and the dorsal scapular nerve and seen in patients with voluntary pos- complicate their care.
rhomboid muscles. terior shoulder subluxation. If the
In contractural winging, contrac- scapula is forcibly held against the
tures about the glenohumeral joint chest wall, preventing winging, the Summary
produce secondary scapular winging. patient may have difficulty sublux-
Patients with obstetric shoulder ating the shoulder. A variety of disorders can cause
trauma may develop contractures Patients with painful shoulders scapular winging. An understand-
due to unbalanced muscle forces with may reflexively limit glenohumeral ing of these disorders and an appre-
the humerus abducted and internally motion. This forces the periscapular ciation of the physical examination
rotated relative to the scapula. When muscles to work in excess, because findings will prevent misdiagnosis
the arm is forcibly adducted to the scapulothoracic motion must in- and assist in directing treatment.
chest wall and externally rotated, the crease to compensate for the limited For most patients, conservative
superior corner of the scapula projects glenohumeral motion. With fatigue treatment, which includes scapular
away from the chest wall at the upper of the periscapular muscles, particu- rehabilitation emphasizing range of
margin of the trapezius, producing larly the serratus anterior, trapezius, motion and periscapular muscle
the “scapular sign of Putti.”39 and rhomboid muscles, secondary strengthening, will alleviate symp-
Contractural winging can also scapular winging occurs. As has toms. If symptoms persist despite
occur with fibrosis of the deltoid.40 been shown,38,40 treatment of the pri- adequate time and conservative
This type of winging decreases when mary glenohumeral disorder will treatment, one should consider the
the arm is raised and increases when alleviate the scapular winging; con- surgical options, which are capable
it is lowered. Fibrosis of the deltoid versely, scapular winging is unlikely of resolving pain and winging.

324 Journal of the American Academy of Orthopaedic Surgeons


John E. Kuhn, MD, et al

References
1. Roy PH, Beahrs OH: Spinal accessory 16. Leffert RD: Pectoralis major transfer for 30. Saeed MA, Gatens PF Jr, Singh S: Wing-
nerve in radical neck dissections. Am J serratus anterior paralysis. Orthop Trans ing of the scapula. Am Fam Physician
Surg 1969;118:800-804. 1992-1993;16:761. 1981;24:139-143.
2. Dewar FP, Harris RI: Restoration of 17. Overpeck DO, Ghormley RK: Paralysis 31. Mendoza FX, Main K: Peripheral nerve
function of the shoulder following paral- of the serratus magnus muscle caused injuries of the shoulder in the athlete.
ysis of the trapezius by fascial sling fixa- by lesions of the long thoracic nerve. Clin Sports Med 1990;9:331-342.
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3. Dunn AW: Trapezius paralysis after plication of infectious mononucleosis: 1930;203:818-823.
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rior cervical triangle. South Med J 1967;49:535-538. ratus anterior disruption: A complica-
1974;67:312-315. 19. Ball CR: Paralysis following injection of tion of rheumatoid arthritis. Arch Phys
4. Wright TA: Accessory spinal nerve antitetanic serum: Case report with ser- Med Rehabil 1986;67:770-772.
injury. Clin Orthop 1975;108:15-18. ratus magnus involved. US Naval Med 34. Weeks LE: Scapular winging due to ser-
5. Bigliani LU, Perez-Sanz JR, Wolfe IN: Bull 1939;37:305-309. ratus anterior avulsion fracture. Orthop
Treatment of trapezius paralysis. J Bone 20. Horwitz MT, Tocantins LM: An Trans 1993;17:184.
Joint Surg Am 1985;67:871-877. anatomical study of the role of the long 35. Levin SE, Trummer MJ: Agenesis of
6. Anderson R, Flowers RS: Free grafts of thoracic nerve and the related scapular the serratus anterior muscle: A cause
the spinal accessory nerve during radi- bursae in the pathogenesis of local of winged scapula. JAMA 1973:225:
cal neck dissection. Am J Surg 1969; paralysis of the serratus anterior mus- 748.
118:796-799. cle. Anat Rec 1938;71:375-385. 36. Wood VE, Marchinski L: Congenital
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Dtsch Z Chir 1924;184:387-397. 27. DePalma AF: Surgery of the Shoulder, 3rd tion contracture of the shoulders and
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14. Fiddian NJ, King RJ: The winged relieved by transplantation of the pec- deltoid contracture in children. J Pediatr
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15. Gregg JR, Labosky D, Harty M, et al: Bone Joint Surg Am 1963;45:156-160. 43. Rowe CR: Unusual shoulder condi-
Serratus anterior paralysis in the young 29. Post M: Pectoralis major transfer for tions, in Rowe CR (ed): The Shoulder.
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825-832. Surg 1995;4:1-9. pp 639-654.

Vol 3, No 6, November/December 1995 325


Genu Varum in Children: Diagnosis and Treatment

Werner C. Brooks, MD, and Richard H. Gross, MD

Abstract

Genu varum is a relatively common finding in children. Physiologic bowing, amined in the frontal and sagittal
which is seen most often, has a well-documented favorable natural history. Idio- planes for asymmetry and align-
pathic tibia vara is the most common of the pathologic conditions that are associ- ment. It should then be determined
ated with bowed legs; treatment strategies vary with the patient’s age and the stage whether the deformity is a gradual
of disease and deformity. Genu varum may also accompany systemic conditions, bowing or an abrupt angulation. If
such as achondroplasia, vitamin D–resistant rickets, renal osteodystrophy, and the deformity is angular, its loca-
osteogenesis imperfecta—all of which can result in short stature. Indications for tion is identified in the distal femur,
intervention are not always well defined. A rare disorder, focal fibrocartilaginous the knee, or the proximal tibia.
dysplasia, usually requires no treatment. Standing radiographs of the entire lower Obliquity of the popliteal crease, if
limbs are necessary for surgical planning, as the deformity can sometimes affect present, is a useful sign; distal
the distal femur rather than the proximal tibia. Restoration of the mechanical axis femoral varus will produce obliq-
of the limb is the principal goal of treatment; the particular type of internal fixa- uity of the popliteal crease, while
tion is of secondary importance. deformity more distal in the ex-
J Am Acad Orthop Surg 1995;3:326-335 tremity will not.
Passive rotation of the hips and
motion of the knee are noted. Liga-
mentous stability of the knee is as-
Genu varum, known colloquially as may be a good source for this infor- sessed, with particular attention to
bowlegs, is relatively common in mation. The ages at attainment of the lateral ligamentous complex. A
children and is a frequent cause of various developmental milestones, dynamic component of the defor-
parental concern. In the vast major- such as sitting independently, mity or lateral thrust at the knee dur-
ity of cases, genu varum will correct pulling to stand, and walking, ing the stance phase of gait indicates
with growth. A small number of should be determined. It is useful to laxity of the lateral ligamentous
children have pathologic conditions establish whether the parents con- complex. Torsion of the tibia should
that may result in functional and sider the deformity to be progres- also be routinely assessed; determi-
cosmetic problems if left untreated. sive. The positional sleeping and nation of the thigh-foot angle and
In this article, we will review perti- sitting habits of the child are also of evaluation of the bimalleolar axis, as
nent factors in the assessment of interest. described by Staheli et al,1 are useful
genu varum, associated conditions,
and treatment options. Physical Examination
After routine documentation of Dr. Brooks is a Resident in the Department of Or-
the height and weight and determi- thopaedic Surgery, Medical University of South
Carolina, Charleston. Dr. Gross is Professor of
Assessment nation of their percentiles for age,
Orthopaedic Surgery and Pediatrics, Medical
the patient’s pelvis, knees, and feet University of South Carolina.
History should be examined carefully.
A thorough history will often dis- Shortening of the limbs relative to Reprint requests: Dr. Gross, Department of Or-
tinguish the relatively infrequent the trunk, especially rhizomelic thopaedic Surgery, Medical University of South
pathologic genu varum from the shortening, suggests a dwarfing Carolina, 171 Ashley Avenue, Charleston, SC
condition. In ambulatory children, 29425.
much more common physiologic va-
riety. A family history of short the appearance while standing and
Copyright 1995 by the American Academy of Or-
stature or similar varus alignment during gait provides the most infor- thopaedic Surgeons.
should be sought; the grandparents mation. Both limbs should be ex-

326 Journal of the American Academy of Orthopaedic Surgeons


Werner C. Brooks, MD, and Richard H. Gross, MD

in torsional assessment. Serial pho-


+20°
tographs of the standing child at the
initial and follow-up evaluations
serve as an inexpensive method of +15°

Varus
documenting any progression of the
deformity. +10°

Radiographs +5°
We believe radiographs are un-
necessary in a young child of normal 0°
stature with physical findings com-
patible with physiologic bowing. -5°
When there is a localized deformity
Valgus
or the child is short, full-length -10°
standing radiographs (hip to ankle)
should be obtained with the knees
-15°
pointing straight forward. When in-
ternal tibial torsion is present, the
1 2 3 4 5 6 7 8 9 10 11 12 13
technician often attempts to exter-
Age, yr
nally rotate the leg (and the knee) to
point the foot straight forward; Fig. 1 Graph illustrating the development of the tibiofemoral angle in children during
however, rotation affects the growth, based on measurements from 1,480 examinations of 979 children. Of the lighter lines,
tibiofemoral and metaphyseal-dia- the middle one represents the mean value at a given point in time, and the other two repre-
sent the deviation from the mean. The darker line represents the general trend. (Adapted
physeal angles and tends to minimize with permission from Salenius P, Vankka E: The development of the tibiofemoral angle in
the degree of deformity.2 In addition children. J Bone Joint Surg Am 1975;57:259-261.)
to the angular deformity present, the
physes of the femur and tibia should
be carefully assessed.
alignment may not be reached until bowing without an acute angular
22 to 24 months of age. Even pro- component. The physis will appear
Physiologic Genu Varum nounced physiologic genu varum normal without medial physeal
greater than 30 degrees can correct changes. There may be equal
Physiologic genu varum is by far the with continuing growth.3 Overcor- beaking of both the distal femoral
most common cause of bowlegs in a rection to excessive genu valgum is and the proximal tibial metaphyses.
toddler. The natural history of the maximal at 4 years of age; the valgus The treatment of physiologic
changing angular relationship be- angulation averages 8 degrees. Cor- genu varum is periodic observation
tween the femur and the tibia in chil- rection to physiologic valgus is usu- and examination, together with edu-
dren is required knowledge for any ally complete by 5 or 6 years of age.4 cation and reassurance of the par-
orthopaedist with a pediatric prac- Early walking has been docu- ents. Occasionally, spontaneous
tice. Development of the tibio- mented in black children,5 and this correction of the physiologic genu
femoral angle follows a predictable may be a factor in a tendency toward varum will be delayed. We believe
sequential pattern. Infantile genu increased physiologic bowing. In- this happens more often in children
varum progresses to excessive genu ternal tibial torsion is frequently who habitually sleep or sit with their
valgum, followed a gradual correc- found in association with physio- legs rotated beneath them, as this
tion to adult physiologic valgus logic genu varum; if physiologic, it seems to counteract the normal un-
alignment (Fig. 1). Genu varum is corrects concomitantly with the winding effect of weight-bearing in
greatest at 6 months of age. Correc- genu varum. correcting tibial torsion and genu
tion to neutral alignment is often Radiographically, physiologic varum.
complete by 18 months of age. genu varum is characterized by Reassurance of anxious parents
Heath and Staheli3 report that per- bowing of the entire limb. On the or other relatives of a child with
sistence of genu varum beyond 2 standing anteroposterior radio- physiologic bowing is not always
years of age is abnormal, and Sale- graph, both the distal femur and the easy to achieve. We find that giving
nius and Vankka4 state that neutral proximal tibia will have some varus a copy of a graph depicting the nor-

Vol 3, No 6, November/December 1995 327


Genu Varum in Children

mal progression of genu varum to form, which is less common than the forces on the medial proximal tibial
genu valgum in early childhood, infantile type. Late-onset tibia vara physis and found that in older chil-
along with the orthopaedist’s expla- is more often unilateral and has a dren, lesser degrees of varus were
nation of the graph, is extremely greater prevalence in black, male, necessary to produce medial phy-
helpful. The parents can then show and obese children and teenagers. In seal growth retardation. In a 2-year-
the graph to other concerned rela- his study of the natural history of old, 20 degrees of varus could
tives. In addition, the American tibia vara in Finnish children, Lan- produce medial tibial physeal
Academy of Orthopaedic Surgeons genskiöld6 reported more rapid pro- growth inhibition; in a 5-year-old of
has produced a video on common gression of the varus deformity in normal weight, as little as 10 degrees
lower-limb problems in children the infantile type than in the late-onset of varus angulation could result in
(“Growing Out of It: Torsional De- type. The prevalence of morbid obe- growth inhibition.
formities in Children” [No. 29-074]), sity in adolescents has increased in
which can be viewed independently the United States,7 and there appears Assessment
by the family. to be an associated increase in the in- Examination of the child with
cidence of late-onset tibia vara. tibia vara is notable for an angular
Children in whom pathologic varus deformity discernible just be-
Tibia Vara tibia vara later develops are born low the knee. In morbidly obese
with normal alignment of the femur children, the acute angulation of the
History and tibia; the deformity results from tibia may be hidden by their exces-
Tibia vara, often referred to as a subsequent growth disturbance of sive soft tissue. In contrast, the
Blount’s disease, is characterized by the proximal tibia. Tibia vara does young child with physiologic genu
an abrupt varus deformity of the not occur in children who do not varum will have a more gentle cur-
proximal tibia. It is the most fre- walk. While the exact etiology of in- vature of the entire extremity. An in-
quent cause of pathologic genu fantile tibia vara remains unclear, an wardly directed thigh-foot angle
varum. Unlike physiologic genu association between tibia vara and due to internal tibial torsion may ac-
varum, Blount’s disease is progres- walking at an early age and obesity company either of these conditions,
sive and rarely corrects sponta- in infancy suggests that mechanical but is more severe in infantile tibia
neously. There are two predominant forces are at least partially causative. vara. A lateral thrust, indicating lax-
types of tibia vara—infantile and Early weight-bearing and obesity re- ity of the lateral ligamentous com-
late-onset, or adolescent—which are sult in greater compressive forces plex, may be seen in children over
distinguished by the age at onset across the medial tibial physis than the age of 3 with tibia vara. This lax-
and the distinctive clinical presenta- in infants who are not obese and ity is thought to exacerbate the dy-
tion. While the two types are simi- who begin walking at about 1 year of namic forces across the physis
lar in the histologic appearance of age. The compressed posteromedial during gait and is not seen in physi-
the proximal tibial physes, the exact physis responds with slower growth ologic bowing.
etiologies remain somewhat un- in this region, producing a progres-
clear. sive varus deformity of the proximal Pathology
Tibia vara is classified as infantile tibia. The histopathologic findings in the
when the onset occurs before 5 years In the late-onset type, there is physes are the same whether the child
of age. Idiopathic infantile tibia vara usually a mild preexisting varus de- has infantile or late-onset tibia vara.8,10
is more often seen in black, female, formity, which is thought to be a The physeal disruption is similar to
and obese children and in children factor in the development of a pro- that found in slipped capital femoral
who begin to walk earlier than gressive varus deformity. When epiphysis, which may suggest a com-
usual. Involvement is bilateral in mild genu varum persists into ado- mon etiology. Disorganized physeal
80% of patients and is associated lescence, increased body weight and cartilage is present, with disruption of
with a greater degree of internal tib- physical activity repetitively trau- the normal columnar architecture of
ial torsion than in the adolescent matize the posteromedial physis, the physis, which is most evident in
form. There may be difficulty in dis- causing medial growth suppres- the resting zone. Islands of densely
tinguishing early infantile tibia vara sion.8 packed, unusually hypertrophic carti-
from physiologic genu varum. Cook et al9 performed a two-di- lage cells are seen. Both fibrovascular
Children in whom significant mensional finite-element analysis of and cartilaginous reparative tissue
tibia vara develops after 6 years of the effect of varus angulation and in- can be found at the physeal-metaphy-
age are thought to have the late-onset creased body weight on resultant seal junction.

328 Journal of the American Academy of Orthopaedic Surgeons


Werner C. Brooks, MD, and Richard H. Gross, MD

Radiographs system does provide the user with line drawn between the medial and
The characteristic radiographic some notion of the natural history of lateral aspects of the tibial metaph-
appearance of tibia vara is not usu- progression of the condition. ysis (Fig. 3). A metaphyseal-diaphy-
ally present until the age of 2 years. Whether a given tibia demonstrates seal angle greater than 11 degrees is
The radiographic classification de- stage III or stage IV changes is less strongly associated with subsequent
veloped by Langenskiöld6 is most of- important than is the recognition development of tibia vara. In their
ten used to stage the infantile forms that tibia vara is well established and study, Levine and Drennan found
of the disease (Fig. 2). The potential the treatment that might be appro- that 29 of 30 affected limbs with a
for recovering growth after treat- priate for stage I or II is no longer metaphyseal-diaphyseal angle over
ment is thought to be directly related appropriate. 11 degrees developed advanced
to the stage of the disease, although In late-onset tibia vara, the radi- radiographic changes consistent
this staging may be more pertinent ographic changes are less dramatic. with the diagnosis of tibia vara, with
in a retrospective review than The growth plate shows less irregu- a false-positive rate of only 3%. In
prospectively. larity and rarely forms the physeal contrast, tibia vara developed in
Medial fragmentation of the bone bridge that may be seen in the only 3 of 59 limbs with metaphyseal-
proximal tibial metaphysis is the infantile form. The epiphysis is less diaphyseal angles of less than 11 de-
earliest abnormal radiographic find- deformed, producing less articular grees.
ing. Later, medial physeal depres- incongruity. Overgrowth of the lat- Feldman and Schoenecker 2
sion and varus angulation of the eral femoral condyle is common, found the metaphyseal-diaphyseal
metaphysis develop, with beaking and distal femoral varus may be pre- angle to be somewhat less reliable
of the proximal tibial metaphysis. In dominant.11 in younger patients. On linear-
very late stages of Blount’s disease, Levine and Drennan12 have popu- regression analysis of the use of a
the medial physis develops an os- larized measurement of the metaph- metaphyseal-diaphyseal angle of 11
seous bridge between the epiphysis yseal-diaphyseal angle of the degrees or more as a basis for de-
and the metaphysis. proximal tibia for the early differen- ciding treatment, they found a
As with the use of many classifi- tiation of infantile tibia vara from false-negative rate of 9% and a
cation systems, there is considerable physiologic genu varum. This angle false-positive rate of 33%.
interobserver variation, and the is formed by a line drawn perpen- With increasing age, the metaph-
staging is not precise. However, the dicular to the tibial diaphysis and a yseal-diaphyseal angle is more reli-

Fig. 2 The six stages of tibia vara, as described by Langenskiöld.6 Stage I (seen in children up to age 3 years) is characterized by medial and
distal beaking of the metaphysis and irregularity of the entire metaphysis. Stage II (seen in children aged 21⁄2 to 4 years) is characterized by a
sharp lateromedial depression in the ossification line of the wedge-shaped medial metaphysis. Complete restoration is common in this stage.
Stage III (seen from ages 4 to 6 years) is characterized by deepening of the metaphyseal beak, which gives the appearance of a step in the me-
dial metaphysis. Stage IV (seen from ages 5 to 10 years) is characterized by enlargement of the epiphysis, which occupies the medial me-
taphyseal depression. Restoration is still possible in this stage. Stage V (seen from ages 9 to 11) is characterized by a cleft in the epiphysis,
which gives the appearance of a double epiphysis; the articular surface of the medial tibia is deformed, sloping distally and medially from
the intercondylar region. Stage VI (seen from ages 10 to 13) is characterized by closure of the medial proximal tibial physis, with a normal
lateral physis. Langenskiöld described his findings on the basis of his observations of Finnish children; changes in African-American chil-
dren tend to occur at a younger age.

Vol 3, No 6, November/December 1995 329


Genu Varum in Children
CALLOUT NEEDED
Although Levine and Drennan12 re- growth is present on radiographs,
ported that a metaphyseal-diaphy- which usually takes about 1 year.
seal angle of 11 degrees could be Thus, bracing is usually not a viable
used as a basis for treatment, others option for children over the age of
have recommended observation of 3.16 Factors such as patient age, stage
children aged less than 24 months of the disease, family compliance,
with metaphyseal-diaphyseal angles and brace fit can have an effect on the
of as much as 16 degrees.2 Persistent success of bracing. Studies control-
internal tibial torsion, lateral thrust ling for all these variables have not
during stance phase in gait, and pos- yet been reported. However, it
terolateral instability are additional seems that bracing is a reasonable
findings that may influence a deci- first treatment option when a deci-
sion to initiate early treatment. sion is made to start treatment of
There is certainly a place for ob- early tibia vara in a 2- or 3-year-old
servation of the young child with ab- child.
normal clinical and radiographic Children who are too old for brac-
findings before initiating brace or ing and children in whom tibia vara
Fig. 3 Determination of the metaphyseal- surgical treatment. A child with a has progressed despite bracing are
diaphyseal (MD) and tibial-femoral (TF) an- metaphyseal-diaphyseal angle of best treated with a proximal tibial
gles.
less than 9 degrees is obviously at valgus osteotomy. The goal of the
minimal risk for tibia vara. If the an- osteotomy is to restore the mechani-
gle is greater than 16 degrees, treat- cal axis of the lower extremity. The
able, since it tends to increase in ment probably should be initiated. osteotomy is performed below the
magnitude in patients who have Children with metaphyseal-diaphy- tibial tubercle apophysis and is com-
Blount’s disease and decrease in seal angles between 9 and 16 degrees bined with a fibular osteotomy.
magnitude in patients with physio- are generally treated if there has Ideally, the osteotomy is done be-
logic genu varum. Rotation can been no tendency toward correction fore the child is 4 years old. Residual
have a small but significant effect on after 24 months of age. internal tibial torsion can be cor-
the radiographic measurement of While early tibia vara will correct rected at the same time. If os-
the metaphyseal-diaphyseal angle. without bracing in some children teotomies are first done in older
Henderson et al13 compared radio- (Fig. 4), bracing has often been rec- children, repeat osteotomies are
graphs obtained with and without ommended as the initial treatment of more often needed. Ferriter and
rotation and found a difference of 2.8 children with Langenskiöld stage I or Shapiro17 retrospectively analyzed
± 1.2 degrees in the metaphyseal- II tibia vara. The device usually pre- factors affecting the outcome of 77
diaphyseal angles that were measured. scribed is a knee-ankle-foot orthosis proximal tibial osteotomies per-
When attempting to distinguish with a single medial upright secured formed on 25 patients with tibia vara
physiologic genu varum from tibia at the upper thigh and ankle. A knee and found a 76% rate of deformity
vara in young patients, this amount hinge is not used, but this does not recurrence in children operated on
of measuring error can be mislead- prevent the child from sitting. The after the age of 4.5 years. In younger
ing if one is relying on the metaphy- ankle is left free. A strap at the knee children, the rate of recurrence of
seal-diaphyseal angle alone for the applies a corrective valgus force. The varus deformity was 31%.
diagnosis. If there is doubt regard- brace is worn nearly full-time, espe- Loder and Johnston14 reported
ing the radiographic findings, we be- cially during walking, to minimize lower rates of recurrent deformity
lieve a further period of observation the valgus stress at the knee. The ef- after valgus tibial osteotomy. Prog-
is indicated, rather than initiating fectiveness of the brace is thought to nostic factors associated with a
treatment on the basis of blind ad- be related to the relief of weight- higher rate of recurrence in their
herence to arbitrary radiographic bearing stresses on the medial phy- older patients included morbid obe-
measurements. seal region of the proximal tibia. sity and more severe disease (Lan-
Brace treatment is reported to be suc- genskiöld stages IV, V, or VI).
Treatment cessful in 50% to 80% of the patients Efforts to improve the results of
There are still no generally ac- treated.14,15 The brace is worn until tibial osteotomy as treatment of in-
cepted criteria for initiation of treat- the deformity has been corrected and fantile tibia vara in children older
ment in infantile tibia vara. reconstitution of medial physeal than 4 years include physeal-bar re-

330 Journal of the American Academy of Orthopaedic Surgeons


Werner C. Brooks, MD, and Richard H. Gross, MD

A B C

Fig. 4 A, Clinical appearance of a healthy


boy, aged 1 year 9 months, being evaluated
for infantile tibia vara. B, Initial radiograph
shows medial tibial physeal beaking and me-
taphyseal-diaphyseal angles of 17 degrees
on the left and 12 degrees on the right. Ob-
servation without bracing was elected at that
time. C, Radiograph obtained at age 2 years
3 months shows persistent medial tibial
beaking and irregularity of the proximal tib-
ial physes, greater on the left than the right.
D, Normal tibial alignment was seen at age 4
years 10 months. E, Clinical appearance at
age 4 years 10 months.

D E

section and lateral proximal tibial vara who are older than 5 years. The Physeal-bridge resection is a diffi-
hemiepiphysiodesis (Fig. 5). These presence of a physeal bridge may be cult operative procedure due to the
procedures were developed with an impossible to ascertain on routine deformity of the physis, and the poor-
understanding that recurrence of the radiographs. Computed tomogra- est results have been associated with
deformity is largely due to the lack phy or magnetic resonance imaging, involvement of more than 30% of the
of reconstitution of growth of the with thin sections obtained through physis.16 Fat, cartilage, Silastic, and
medial proximal tibial physis. the physis, can be helpful in detect- methylmethacrylate have all been
Physeal bridges are more com- ing the presence and size of the os- used as spacers to prevent bridge re-
mon in children with infantile tibia seous bridge. currence after surgical resection. Fa-

Vol 3, No 6, November/December 1995 331


Genu Varum in Children

A B C

Fig. 5 A, Radiograph of a 7-year-old girl with unilateral varus deformity and severe depression of the medial tibial physis. B, A corrective
closing-wedge proximal tibial osteotomy was performed, with stapling of the lateral proximal tibial physis. C, On radiograph obtained at 2-
year follow-up examination, alignment is normal, with minimal leg-length discrepancy.

vorable outcomes in small series of greater), resultant deformity of the Treatment of the adolescent with
patients have been reported.14,18 Ac- tibial epiphysis, as well as the physis, tibia vara often involves increased
tual growth, however, is difficult to produces articular incongruity. technical problems due to morbid
determine from the published radio- Restoration of normal articular obesity. Complications are more
graphs, and our personal experience anatomy by elevation of the de- common than in the treatment of in-
with this procedure has been poor. A pressed medial epiphysis and physis fantile tibia vara. These complica-
rim of viable physis surrounding the has been reported to reconstruct the tions include difficulty in the
excised portion is necessary if growth joint architecture, generally in com- exposure and performance of the os-
is to recover after partial physeal re- bination with a valgus tibial os- teotomy and failure of osteotomy
section. It may not be possible to de- teotomy to restore the alignment of fixation. For these reasons, Hender-
termine on gross examination at the the lower limb.19 Medial elevation son et al21 have proposed lateral
time of surgery whether the remain- combined with proximal tibial os- proximal tibial hemiepiphysiodesis
ing physeal rim is biologically active. teotomy (and occasionally distal as a primary procedure, reserving
The use of lateral hemiepiphys- femoral osteotomy) has been utilized osteotomy for those cases in which
iodesis of the proximal tibial physis with success by Schoenecker et al.15 more conservative procedures have
is an attractive treatment alternative For patients with late-onset tibia failed. The importance of standing
in the older child with tibia vara at vara, the indication for treatment has radiographs of the entire lower
risk for redevelopment of varus de- been defined arbitrarily as varus limbs has recently been empha-
formity after proximal tibial os- alignment greater than approxi- sized.11 We believe such radio-
teotomy alone. A formal ablation of mately 10 degrees. The goal of graphs are necessary for proper
the lateral tibial physis or simple sta- surgery is correction of the mechani- preoperative planning and postop-
pling can be done (Fig. 5). When cal axis to prevent the development of erative assessment. The literature is
done unilaterally, a limb-length dis- medial knee-compartment osteo- replete with techniques for the per-
crepancy is predictable in younger arthrosis. Young adults with tibia formance of the tibial osteotomy in
patients; however, treatment of this vara have a high incidence of acceler- late-onset tibia vara, including vari-
inequality may not be needed.15 ated symptomatic degenerative ous types of internal and external
In advanced forms of infantile changes of the knee, which is related fixation. Regardless of the method
tibia vara (Langenskiöld stage IV or to the degree of varus malalignment.20 of fixation chosen, the goals of

332 Journal of the American Academy of Orthopaedic Surgeons


Werner C. Brooks, MD, and Richard H. Gross, MD

surgery are unchanged: correction of have a high incidence of growth dis- yseal dysplasias can lead to bowing,
the mechanical axis and leveling of turbance in both the proximal and among them the Jansen and Schmid
the knee joints. distal ends of the tibia. The physes types. The more severe Jansen type
in these children have been shown to has an autosomal-dominant inheri-
exhibit many of the same pathologic tance and is characterized by mental
Differential Diagnosis changes found in tibia vara and retardation, short-limb dwarfism,
slipped capital femoral epiphysis, exophthalmia, hypercalcemia, and
Vitamin D–Resistant Rickets particularly disorganized growth long-bone bowing. The more mild
Progressive genu varum often de- plates at the physeal-metaphyseal Schmid type, which is also transmit-
velops in children with untreated junction.23 Deformity results when ted by autosomal-dominant inheri-
hypophosphatemic rickets, a sex- eccentric forces occur across the tance, is characterized by normal
linked inherited disorder due to vit- weakened physis. Because renal intellect and normal laboratory find-
amin D resistance that results in failure occurs more commonly in ings. As lower-extremity bowing
defective bone mineralization. Chil- older children who have already does occur with this condition, it
dren with this disorder typically achieved physiologic valgus align- may be difficult to distinguish from
present with bilateral lower-limb an- ment, valgus deformity is encoun- rickets. Even though the physes are
gular deformities. The diagnosis tered most often at the knee. widened and cupped in the Schmid
should be considered if the child is Younger children who have retained type, the epiphyses are normal, and
relatively short, because height in af- physiologic varus alignment may the presence of short stature should
fected children is usually in the undergo exaggeration of preexisting be helpful in arriving at the correct
lower 10th percentile. The bowing is genu varum. Deformities secondary diagnosis.
due to a combination of varus of the to renal disease are usually bilateral,
distal femur and varus of the proxi- with a gentle curve of the extremity Achondroplasia
mal tibia. due to simultaneous involvement of Genu varum is a frequent finding
Medical treatment of this type of both the distal femoral and proximal in achondroplasia, a rhizomelic
rickets includes oral phosphates and tibial physes. dwarfing condition due to abnormal
some form of vitamin D replacement. Rickets and renal osteodystrophy endochondral bone formation. At
Surgical measures to correct the de- may be easily distinguished from birth, lower-limb alignment is rela-
formity are often unsuccessful when tibia vara on the basis of their radio- tively normal. However, with
adequate medical control of the rick- graphic appearance. In both, phy- growth, the spontaneous correction
ets has not been achieved before seal cupping and widening occur at to genu valgum does not occur. In-
surgery. In that situation, it may be both the distal femoral and proximal stead, genu varum tends to increase
best to wait until skeletal maturity to tibial physes. Marked osteopenia throughout childhood and adoles-
realign the mechanical axis.22 When and thinning of cortical bone are also cence, largely due to overgrowth of
only partially treated, this condition present. the fibula in relation to the tibia. In
may be difficult to distinguish from Orthopaedic treatment of angular addition, the growth of the proximal
physiologic bowing, but children lower-limb deformities resulting tibial metaphysis may be asymmet-
with rickets typically are older. Mas- from renal disease is wisely post- rical. Radiographically, the proxi-
sive doses of a vitamin D preparation poned until the renal status has sta- mal fibular physis is superior to the
can restore a normal radiographic bilized in response to medical proximal tibial physis. Although the
appearance to the epiphysis; how- treatment or renal transplantation. tibial metaphysis is enlarged, the
ever, normal growth will not be Correction of genu varum or valgum epiphysis remains normal.
restored unless phosphate replace- with osteotomy will be short-lived Children with achondroplasia
ment is also adequate. Phosphate re- unless the abnormal bone metabo- rarely have knee pain, and function-
placement therapy has to be lism resulting from the renal disease al indications for surgical correc-
administered at regular intervals, has been reversed. tion of bowlegs are not well defined.
and patient compliance with this Treatment options include proximal
strict dosage schedule may be poor. Metaphyseal Chondrodysplasia fibular epiphysiodesis and tibial os-
Metaphyseal chondrodysplasia, teotomy. A fibular epiphysiodesis
Renal Failure and Renal which results from abnormal chon- must be done early in childhood to
Osteodystrophy droblast function and chondroid prevent the development of progres-
Children who are in renal failure production, is a very rare cause of sive genu varum. For established
or who have renal osteodystrophy genu varum. A number of metaph- genu varum, proximal tibial valgus

Vol 3, No 6, November/December 1995 333


Genu Varum in Children

osteotomy is most often used. An formity is more properly termed of the entire lower limbs are required
accompanying distal tibial os- tibia vara. The deformity is usually for the evaluation of the mechanical
teotomy and concomitant tibial apparent to the parents before the axis and the site of deformity.
lengthening have also been advo- child is 18 months of age. Radio- (4) Shortness of stature should
cated by some. The role of lengthen- graphs show a characteristic cortical signal the likelihood that a constitu-
ing of short limbs in this condition is lucency with surrounding sclerosis tional disorder is the cause of genu
still unsettled. Bracing is ineffective, in the proximal medial tibial me- varum.
in part because of the joint laxity taphysis and varus angulation. The (5) Idiopathic tibia vara is the
commonly present. condition usually corrects by age most common pathologic cause of
4 with growth. Surgical correction bowlegs in the child. Bracing may be
Osteogenesis Imperfecta of the deformity is usually not effective in the early stages, but this
Osteogenesis imperfecta results needed.25 has not been established by prospec-
from a defect in type I collagen and tive controlled clinical trials.
produces varying degrees of skeletal Less Common Causes (6) Surgical correction of tibia
fragility. In the more severe forms, Any disorder that can affect the vara can be guided by the principle
multiple fractures of the lower ex- proximal tibial or distal femoral that reestablishing a normal me-
tremities are common. The femur is growth plate has the potential for chanical axis in the early stages will
most frequently fractured, followed causing genu varum. For example, allow normal growth to occur. In
by the tibia. Repeated fractures of- infantile osteomyelitis with abscess older children, resumption of nor-
ten lead to bowing and torsional de- formation can generate uneven sub- mal growth cannot be assumed, and
formities of the lower extremity. The sequent growth, with resultant de- measures to slow later tibial physeal
distal third of the femur is a common formity. Another such disorder is growth may also be needed.
location of these fractures, usually physeal growth disturbance sec- (7) There are various types of in-
associated with anterolateral angu- ondary to trauma or sepsis. The dis- ternal and external fixation, all of
lation at the fracture site. Residual tal femur is a relatively common site which are satisfactory. The particu-
deformity after fracture is common, of growth disturbance following lar type of fixation used for surgical
and the varus angulation often in- physeal fracture. Physeal fractures treatment of tibia vara is less impor-
creases as a result of repeated frac- of the proximal tibia are much less tant than reestablishment of the me-
tures. Radiographs demonstrate common. Management of physeal chanical axis.
diffuse osteopenia, occasionally ac- growth disturbances is complex and (8) Treatment of genu varum sec-
companied by evidence of fracture is beyond the scope of this article. ondary to constitutional disorders
healing at multiple locations. must be tailored on an individual
In cases of mild deformity, bracing basis.
can be used for support and prophy- Principles of Evaluation
laxis against repeat fractures. Occa- and Treatment
sionally in more severe cases, Conclusion
pronounced bowing is present from The following are a few principles
birth, and ambulation will not be pos- that will help the orthopaedist in the Although genu varum is fairly com-
sible unless correction is undertaken evaluation and treatment of the mon in children, considerable
early. There are a number of options child with genu varum: changes in evaluation and treat-
for the surgical management of varus (1) Genu varum is physiologic ment approaches have occurred
deformity secondary to osteogenesis until the age of 18 to 24 months, and over the past decade. Further re-
imperfecta; selection is dependent on treatment is unnecessary. finements can be expected in the
the age of the patient and the nature (2) In a child with normal stature coming years, perhaps including a
of the anatomic deformity. and findings compatible with physi- clearer concept of the etiology of
ologic bowing, radiographic docu- tibia vara, a better grasp of the role
Focal Fibrocartilaginous mentation is unnecessary. If of bracing in infantile tibia vara,
Dysplasia documentation of the condition is and a more complete understand-
Focal fibrocartilaginous dyspla- desired, photographs are less expen- ing of the effects of treatment (both
sia is a rare cause of unilateral genu sive and just as valuable. positive and negative) in consti-
varum.24,25 It affects the proximal (3) If radiographs are deemed tutional disorders such as achon-
medial tibia, and the resultant de- necessary, full-length standing films droplasia.

334 Journal of the American Academy of Orthopaedic Surgeons


Werner C. Brooks, MD, and Richard H. Gross, MD

References
1. Staheli LT, Corbett M, Wyss C, et al: 10. Carter JR, Leeson MC, Thompson GH, 18. Beck CL, Burke SW, Roberts JM, et al:
Lower-extremity rotational problems in et al: Late-onset tibia vara: A histo- Physeal bridge resection in infantile
children: Normal values to guide man- pathologic analysis—A comparative Blount disease. J Pediatr Orthop 1987;
agement. J Bone Joint Surg Am 1985; evaluation with infantile tibia vara and 7:161-163.
67:39-47. slipped capital femoral epiphysis. J 19. Siffert RS: Intraepiphyseal osteotomy
2. Feldman MD, Schoenecker PL: Use of Pediatr Orthop 1988;8:187-195. for progressive tibia vara: Case report
the metaphyseal-diaphyseal angle in 11. Kline SC, Bostrum M, Griffin PP: and rationale of management. J Pediatr
the evaluation of bowed legs. J Bone Femoral varus: An important compo- Orthop 1982;2:81-85.
Joint Surg Am 1993;75:1602-1609. nent in late-onset Blount’s disease. J Pe- 20. Hofmann A, Jones RE, Herring JA:
3. Heath CH, Staheli LT: Normal limits of diatr Orthop 1992;12:197-206. Blount’s disease after skeletal maturity.
knee angle in white children: Genu 12. Levine AM, Drennan JC: Physiological J Bone Joint Surg Am 1982;64:1004-1009.
varum and genu valgum. J Pediatr Or- bowing and tibia vara: The metaphy- 21. Henderson RC, Kemp GJ Jr, Greene WB:
thop 1993;13:259-262. seal-diaphyseal angle in the measure- Adolescent tibia vara: Alternatives for
4. Salenius P, Vankka E: The development ment of bowleg deformities. J Bone Joint operative treatment. J Bone Joint Surg
of the tibiofemoral angle in children. J Surg Am 1982;64:1158-1163. Am 1992;74:342-350.
Bone Joint Surg Am 1975;57:259-261. 13. Henderson RC, Lechner CT, DeMasi 22. Evans GA, Arulanantham K, Gage JR:
5. Illingworth RS (ed): The Development of RA, et al: Variability in radiographic Primary hypophosphatemic rickets: Ef-
the Infant and Young Child: Normal and measurement of bowleg deformity in fect of oral phosphate and vitamin D on
Abnormal, 9th ed. Edinburgh: Churchill children. J Pediatr Orthop 1990;10:491- growth and surgical treatment. J Bone
Livingstone, 1987. 494. Joint Surg Am 1980;62:1130-1138.
6. Langenskiöld A: Tibia vara: Osteochon- 14. Loder RT, Johnston CE II: Infantile tibia 23. Oppenheim WL, Shayestehfar S,
drosis deformans tibiae—Blount’s dis- vara. J Pediatr Orthop 1987;7:639-646. Salusky IB: Tibial physeal changes in
ease. Clin Orthop 1981;158:77-82. 15. Schoenecker PL, Meade WC, Pierron renal osteodystrophy: Lateral Blount’s
7. Henderson RC, Kemp GJ, Hayes PRL: RL, et al: Blount’s disease: A retrospec- disease. J Pediatr Orthop 1992;12:774-
Prevalence of late-onset tibia vara. J Pe- tive review and recommendations for 779.
diatr Orthop 1993;13:255-258. treatment. J Pediatr Orthop 1985;5:181- 24. Olney BW, Cole WG, Menelaus MB:
8. Wenger DR, Mickelson M, Maynard JA: 186. Three additional cases of focal fibrocar-
The evolution and histopathology of 16. Greene WB: Infantile tibia vara. J Bone tilaginous dysplasia causing tibia vara.
adolescent tibia vara. J Pediatr Orthop Joint Surg Am 1993;75:130-143. J Pediatr Orthop 1990;10:405-407.
1984;4:78-88. 17. Ferriter P, Shapiro F: Infantile tibia 25. Bradish CF, Davies SJM, Malone M:
9. Cook SD, Lavernia CJ, Burke SW, et al: A vara: Factors affecting outcome following Tibia vara due to focal fibrocartilagi-
biomechanical analysis of the etiology of proximal tibial osteotomy. J Pediatr Or- nous dysplasia: The natural history. J
tibia vara. J Pediatr Orthop 1983;3:449-454. thop 1987;7:1-7. Bone Joint Surg Br 1988;70:106-108.

Vol 3, No 6, November/December 1995 335


Paget's Disease of Bone: Pathophysiology,
Diagnosis, and Management

Frederick S. Kaplan, MD, and Frederick R. Singer, MD

Abstract

Paget’s disease of bone is a common geriatric disorder of skeletal remodeling, Pathology


which may have a viral etiology. Safe and effective treatments are now available
for associated complications of symptomatic involvement. The orthopaedic sur- Paget’s disease is a focal disorder of
geon should have a fundamental understanding of the complications of Paget’s skeletal remodeling in which the pri-
disease and should be familiar with the indications for treatment, as well as avail- mary cellular abnormality is an
able medical and surgical therapies. increase in osteoclastic resorption of
J Am Acad Orthop Surg 1995;3:336-344 bone (Fig. 1). Increased bone resorp-
tion leads to a compensatory
increase in bone formation. The
The orthopaedic surgeon is often The prevalence has been reported to overall rate of bone remodeling is
involved with family practitioners, be 10% to 15% by the ninth decade of accelerated, resulting in a predomi-
general internists, endocrinologists, life. The disorder is rarely recog- nance of highly vascular bone that is
and rheumatologists in the diagno- nized before age 40. structurally weak and prone to
sis and care of patients who have Several members of a family may deformities and pathologic frac-
Paget’s disease of bone. The ortho- manifest Paget’s disease. As many tures.1,2,4,5
paedic surgeon may be recruited to as 25% of patients have one or more Pagetic osteoclasts are more
render a definitive diagnosis, to par- family members who also have the numerous and larger than normal
ticipate in patient education, to pre- disorder. The cumulative incidence osteoclasts and may contain as many
scribe medical or physical therapy, of Paget’s disease to age 90 is as 100 nuclei per cell. These bone-
or to perform a surgical procedure. approximately four times greater in resorbing cells often contain nuclear
Accordingly, the orthopaedic sur- relatives of patients with the condi- and cytoplasmic inclusions, which
geon should be familiar with all tion than in relatives of control sub-
aspects of diagnosis and available jects. In many families, genetic
medical and surgical treatments for susceptibility is also suggested by Dr. Kaplan is Associate Professor of Orthopaedic
Surgery and Medicine and Chief, Division of
patients who have Paget’s disease. the finding of a linkage between the Metabolic Bone Diseases and Molecular
This article will review the epidemi- HLA-DQW1 haplotype and the Orthopaedics, University of Pennsylvania
ology, pathology, etiology, patho- presence of Paget’s disease. These School of Medicine, Philadelphia. Dr. Singer is
physiology, diagnosis, and medical data do not establish a genetic basis Director, Endocrine-Bone Disease Program,
management of Paget’s disease of for the disease, but rather define John Wayne Center Institute at St. John’s Hospi-
tal and Health Center, Santa Monica, Calif, and
bone. familial characteristics that have Clinical Professor of Medicine, University of Cal-
been observed in a large number of ifornia at Los Angeles School of Medicine.
affected patients.3
Epidemiology There is a striking geographic dis- Reprint requests: Dr. Kaplan, Department of
tribution of Paget’s disease. The dis- Orthopaedic Surgery, University of Pennsylva-
Paget’s disease of bone, or osteitis ease is most prevalent in England, nia School of Medicine, 3400 Spruce Street,
Philadelphia, PA 19104-4283.
deformans, is a common geriatric western Europe, the United States,
problem, occurring in 3% to 4% of Australia, and New Zealand, but is Copyright 1995 by the American Academy of
the population over 50 years of age.1 uncommon in Scandinavia, China, Orthopaedic Surgeons.
It is slightly more common in men.2 Japan, and India.4

336 Journal of the American Academy of Orthopaedic Surgeons


Frederick S. Kaplan, MD, and Frederick R. Singer, MD

therefore no longer capable of being


cultured.
Current data suggest that Paget’s
disease may be caused by hematoge-
nous infection with one of several
possible paramyxoviruses and that
following an acute viremia, osteo-
clasts or their precursors become
chronically infected. According to
this hypothesis, the virus mutates
rapidly and loses its infectivity but is
able to stimulate osteoclast prolifera-
tion and activity, possibly by
cytokine production. This may
induce dramatic local osseous
effects.7,8 Various familial and
genetic factors may be involved in
A B
susceptibility and immunologic reac-
Fig. 1 Light- and electron-microscopic findings in Paget’s disease. A, Section of bone shows tivity to the putative infectious agent,
intense osteoclastic and osteoblastic activity and mosaic of lamellar bone. B, Electron-micro- which would likely influence the clin-
scopic view of multinucleated osteoclast with nuclear inclusions that may be viruses
(arrows). N = nuclei; C = cytoplasm. (Reproduced with permission from Netter FH: The
ical expression of the disease.3,5,6,9
CIBA Collection of Medical Illustrations. Summit, NJ: CIBA-Geigy Corp, 1987, vol 8, pt I, p 238.)

Clinical Manifestations and


Complications
resemble nucleocapsids of the erratic pattern of cement lines. This
Paramyxoviridae family of viruses.6 mosaic pattern is a consequence of Paget’s disease may affect any bone
The pathologic process in Paget’s accelerated bone resorption and for- and may be monostotic or polyos-
disease may be divided into active mation.5 totic. Clinical manifestations vary,
and inactive phases. Early in the depending on the sites and severity
active phase, intense osteoclastic of lesions (Tables 1 and 2). Many
bone resorption prevails (lytic Etiology individuals with radiologic evidence
phase). Later, compensatory bone of the disease have no symptoms and
formation is apparent (mixed A number of hypotheses have been may not require treatment.1,2,4 In fact,
phase). Very late in the active phase, proposed to explain the genesis of because Paget’s disease is usually
osteoblastic bone formation pre- Paget’s disease. The most likely asymptomatic, it most often is
dominates (sclerotic phase). Occa- cause is a slow viral infection of detected incidentally on radiographs
sionally, the disease may reach an bone,7 perhaps with an underlying obtained for other purposes or is sug-
inactive phase in which a sclerotic familial predisposition. gested by the unexpected elevation
lesion may remain in the absence of Immunohistologic studies of of serum alkaline phosphatase activ-
excessive bone-cell activity. In such pagetic osteoclasts have revealed ity on a routine serum chemistry
a lesion, the adjacent marrow con- the antigens of paramyxoviruses, screening panel.
sists predominantly of fat cells with particularly the measles and respi- In symptomatic patients, bone
few areas of hematopoietic or ratory syncytial viruses. Further pain can be mild to severe and is
fibrovascular elements.5 support of a viral etiology is pro- usually unrelated to physical activi-
Pagetic bone is usually lamellar vided by the finding of the mRNA ty. Acute pain may develop as a
and fully mineralized. In very active of paramyxoviruses in some patho- consequence of pathologic fractures
lesions, however, immature woven logic material. Although an infec- of affected bone. A variety of other
bone may be present in regions of tious virus has not yet been isolated local and general signs and symp-
poorly mineralized osteoid. The from long-term cultures of pagetic toms may also occur.
affected bone has a characteristic bone cells, this does not eliminate The characteristic bone enlarge-
mosaic pattern with irregularly a viral etiology, because the puta- ment that occurs with Paget’s dis-
shaped areas of lamellar bone and an tive virus is highly defective4,6 and ease may cause spinal stenosis,

Vol 3, No 6, November/December 1995 337


Paget’s Disease of Bone

exacerbating the neurologic symp- ease) and immobilized patients.


Table 1 toms and signs accompanying the The association of mild hyperparathy-
Common Diagnostic Features of
stenosis.10 roidism and Paget’s disease has been
Paget’s Disease of Bone
The function of the cranial nerves reported, but its significance is
may also be affected. Pagetic in- unclear and may be coincidental.1,4
History
volvement of the temporal bone is a The most serious complication of
Rare before 40 years of age
common cause of conductive hear- Paget’s disease is the development
Insidious onset of symptoms
(pain, deformity, headache) ing loss in this condition. Less com- of a malignant bone tumor.13
Often asymptomatic monly, involvement of the cochlea Osteosarcomas, chondrosarcomas,
Physical findings results in mixed sensory and con- fibrosarcomas, and tumors of mixed
Bone deformity and enlargement ductive deafness. Extreme thicken- histologic characteristics may
Increased heat (due to increased ing and enlargement of the skull develop, almost always in a preex-
blood flow) over affected bone may result in platybasia and, in rare isting pagetic lesion. Primary giant
Bone tenderness instances, impaired cerebrospinal cell tumors and secondary meta-
Asymmetric limb involvement fluid flow and hydrocephalus.9 static spread of carcinoma to pagetic
Associated neurologic involve- Painful fissure fractures, pseudo- bone are also quite common.
ment
fractures (transverse radiolucent Paget’s sarcoma, a rare complica-
Associated pagetic arthritis
areas on the convex side of a long tion, occurs in fewer than 1% of
Biochemical findings
Increased serum alkaline phos- bone), and complete pathologic frac- affected patients and is rare before
phatase level tures (transverse “chalk-stick” frac- 70 years of age.13 A marked and sus-
Increased urinary excretion of tures) may occur in areas of high tained increase in pain in an area of
pyridinoline cross-links stress, particularly in the weight- long-standing Paget’s disease in an
Radiologic findings bearing bones of the lower limbs. elderly patient suggests this serious
Metaphyseal involvement Fracture healing may be impaired, sequela. Other manifestations are
Sclerotic and lytic changes in resulting in delayed union or night pain and radiographic evi-
same bone nonunion. This complication is most dence of bone destruction. Serum
Coarse, thick trabeculae common with fractures of the alkaline phosphatase activity may
Enlargement of bone
femur.1,4,5 be unaltered and thus is not a useful
Associated arthritic changes
Articular disorders commonly test. Rapid worsening of bone pain
(late)
Increased radionuclide uptake associated with Paget’s disease of or deformity should indicate the
on technetium-99m methylene bone are degenerative arthritis, cal- need for radiologic evaluation, fol-
diphosphonate bone scan cific periarthritis, and gout. 11,12 lowed by bone biopsy if suspicion of
Bone pathology findings (often Degenerative arthritis in joints con- a tumor remains. Magnetic reso-
from surgical specimens) tiguous with pagetic bone is likely to nance imaging and computed
Disordered remodeling occur because of accelerated remod- tomography are particularly helpful
Increased osteoclastic and eling of the affected bone, which in delineating the presence of bone
osteoblastic activity results in juxta-articular bone tumors. Despite recent advances in
Giant osteoclasts enlargement, abnormal joint biome- the treatment of malignant bone
Mosaic pattern of lamellar bone
chanics, and altered subchondral tumors, the prognosis remains very
Presence of woven bone
support. When the hip is affected, poor in patients who have Paget’s
Virus-like inclusions in nuclei
and cytoplasm of osteoclasts acetabular protrusion along with disease.13 There are currently no
on electron microscopy medial joint-space narrowing may data to support the preventive
result.1,2,4 The association of gout effects of chronic suppressive med-
with Paget’s disease may be sec- ical therapy on the risk of pagetic
ondary to hyperuricemia due to sarcoma.
accelerated nucleic acid turnover in
resulting in spinal radiculopathy or subjacent bone.11,12
cauda equina syndrome.10 Increased Metabolic complications of Diagnostic Evaluation
blood flow to the highly vascular Paget’s disease are uncommon but
pagetic bone has been thought to include hypercalciuria and hyper- The initial evaluation of a patient
provoke the “steal syndrome.” In calcemia.1,4 These complications are with Paget’s disease should include
this situation, blood is shunted seen in only the most severely a complete history and physical
away from the neural elements, involved (polyostotic Paget’s dis- examination, a radionuclide bone

338 Journal of the American Academy of Orthopaedic Surgeons


Frederick S. Kaplan, MD, and Frederick R. Singer, MD

radioisotope scanning. Localization


Table 2 of the bone-seeking agent Tc-99m
Manifestations of Paget’s Disease of Bone
methylene diphosphonate is depen-
dent on the relative vascularity of
Nonskeletal the bone and the extent of hydroxy-
Neurologic
apatite crystal surface available for
Hearing loss and, less commonly, other cranial nerve deficits
binding of the compound. Bone
Spinal-cord or nerve-root compression
Cardiovascular scans are far more sensitive than
Increased cardiac output due to increased bone vascularity radiographs in detecting occult
Possible high-output congestive heart failure pagetic lesions, although inactive
Metabolic sclerotic lesions may be missed.
Hypercalcemia, hypercalciuria, and urolithiasis in immobilized patients The diagnosis of Paget’s disease is
Hyperuricemia and gout usually established on the basis of
Primary hyperparathyroidism (possibly coincidental) the characteristic radiographic
Dental appearance of the lesions. The earli-
Poor occlusion est lesions of Paget’s disease are
Tooth loosening and loss
osteolytic and are most readily
Oncologic
observed in the skull and long bones
Pagetic osteosarcoma
Pagetic chondrosarcoma (Fig. 3). In the skull, discrete oval or
Pagetic fibrosarcoma round areas of osteolysis are termed
Tumors of mixed histologic characteristics osteoporosis circumscripta. In the
Primary giant cell tumors limbs, the disease usually begins as
Skeletal localized metaphyseal involvement.
Axial skeleton The osteolytic lesion usually has a V
Back pain due to vertebral body involvement or arrowhead shape at its advancing
Osteoarthritis of facet joints edge. Lesions have been observed to
Diskogenic disease secondary to vertebral involvement and alteration of progress slowly toward the opposite
nourishment to disk
end of the affected long bone at a rate
Spinal stenosis (due to vertebral body enlargement)
of approximately 1 cm/yr in un-
Spinal-artery steal syndrome with paraparesis and/or paraplegia
Compression fractures of vertebral bodies treated patients.2,4
Neoplastic degeneration As the osteolytic process pro-
Appendicular skeleton gresses to involve much of the long
Bone pain and tenderness bone or skull, the more familiar
Progressive deformity osteosclerotic lesions of Paget’s dis-
Secondary osteoarthritis ease replace the earlier osteolytic
Pathologic fractures with high rate of delayed union, nonunion, or regions. Over a period of years to
malunion decades, the bone becomes chaotic
Neoplastic degeneration in structure and thickened. The
overall bone size may increase
remarkably.
In the lower limbs, bowing, pseu-
scan, appropriate radiographs, and dence of the disease (Fig. 2). A bone dofractures, and complete transverse
baseline laboratory tests (serum scan should be performed when pathologic fractures are common.
alkaline phosphatase, calcium, there is a question about the meta- The latter chalk-stick fractures (Fig. 4)
phosphorus, and albumin determi- bolic activity of a specific region of can also be seen in osteomalacia or
nations).2,4 the skeleton or when it is desirable to fibrous dysplasia. Subchondral bone
document the full extent of the dis- involvement in the metaphysis on
Radiologic Studies ease. A complete radiographic exam- one side of a diarthrodial joint may
Radioisotope studies should be ination should be obtained, including lead to joint incongruity and subse-
performed to evaluate the metabolic all skeletal sites that demonstrate an quent arthritis.
activity of a pagetic lesion, as well as increase in radionuclide uptake.2,4 In patients with back pain, mag-
to assess the total skeletal involve- Technetium-labeled bisphospho- netic resonance imaging and com-
ment in a patient who has focal evi- nates are most commonly used in puted tomography have been

Vol 3, No 6, November/December 1995 339


Paget’s Disease of Bone

A B C

D E F

Fig. 2 Images of a patient with Paget’s disease. A, Bone scan shows areas of increased isotope uptake. B, Proximal humerus appears thick-
ened and coarsely trabeculated, with patchy rarefaction. C, Proximal femur shows typical manifestations of the disease, including osteoscle-
rotic and osteolytic areas, bone enlargement, and metaphyseal involvement with coarse trabeculation. D, Disease involvement can be seen
throughout the pelvis and the proximal femurs, with involvement of the hip joints. E, The body of L3 appears enlarged, with increased den-
sity. F, Myelogram shows obstruction of the vertebral canal at L3. (Reproduced with permission from Netter FH: The CIBA Collection of Medi-
cal Illustrations. Summit, NJ: CIBA-Geigy Corp, 1987, vol 8, pt I, p 237.)

particularly useful in defining the particularly helpful in differentiat- useful biochemical test for Paget’s
extent of degenerative arthritis, ing Paget’s disease from lymphoma disease. The activity of this enzyme,
spinal stenosis, and nerve-root or metastatic carcinoma. which is located in the plasma mem-
impingement.10 An increase in the brane of osteoblasts, reflects the num-
size of a vertebral body is one of the Biochemistry ber and functional state of osteoblasts
radiographic hallmarks of Paget’s The measurement of serum alka- in patients who have bone disease. In
disease of the spine, which can be line phosphatase activity is the most Paget’s disease, the level of alkaline

340 Journal of the American Academy of Orthopaedic Surgeons


Frederick S. Kaplan, MD, and Frederick R. Singer, MD

and inexpensive biochemical index of benefit is commonly overlooked in


disease activity. In selected patients, practice. Narcotic agents should be
new assays specific for bone alkaline avoided, if possible, particularly in
phosphatase may be helpful. the older population.
Urinary excretion of pyridinoline A cane can be a very important
cross-links, a biochemical index of therapeutic device for patients with
bone-matrix collagen resorption, is Paget’s disease of the lower limbs.
measured over 24 hours. As with Because of the benefits of increased
serum alkaline phosphatase activity, stability, prevention of falls, and
urinary excretion of pyridinoline load-sharing capability, the use of a
cross-links correlates well with the cane makes good sense and should
extent of pagetic involvement. 14 be standard treatment for the elderly
Because of the expense and inconve- patient.
nience, this test is not generally used The most important indications
routinely in the assessment or follow- for treatment of Paget’s disease
up of a patient with Paget’s disease.1,2,4 include bone pain, neurologic
Due to tight metabolic coupling involvement, high-output cardiac
between bone resorption and bone failure, prevention of fracture or
formation, calcium levels in the skeletal deformity in young patients
serum and urine are usually normal
except when there is concurrent gen-
eralized immobilization, hyperthy-
roidism, hyperparathyroidism, or
malignancy.1,2,4

General Diagnostic and


Treatment Considerations

Not everyone with Paget’s disease


will require treatment. In many
cases, the symptoms that cause the
patient to seek care are due to an
associated disorder. Therefore, a
careful consideration of the symp-
Fig. 3 Characteristic early lesions of Paget’s
toms and the physical and radio-
disease. Top, Lateral radiograph shows graphic findings is necessary to
patchy density of the skull, with areas of determine whether treatment of
osteopenia (osteoporosis circumscripta
cranii). Bottom, Radiographic findings in
Paget’s disease is indicated.
the tibia include thickening, bowing, coarse Nonsteroidal anti-inflammatory
trabeculation, and an advancing radiolucent medications and aspirin continue to
wedge. (Reproduced with permission from
Netter FH: The CIBA Collection of Medical
have an important role in treating
Illustrations. Summit, NJ: CIBA-Geigy Corp, the arthritis associated with joint
1987, vol 8, pt I, p 236.) destruction in Paget’s disease. Rou-
tinely, patients with end-stage
Paget’s disease have low alkaline
phosphatase levels, limited disease
phosphatase activity correlates activity, and moderate joint degen-
roughly with the extent of skeletal eration, which can be symptomati- Fig. 4 Healing chalk-stick fracture. (Repro-
involvement as established by cally controlled with non-steroidal duced with permission from Netter FH: The
CIBA Collection of Medical Illustrations. Sum-
radioisotope bone scanning. Serial anti-inflammatory agents. The mit, NJ: CIBA-Geigy Corp, 1987, vol 8, pt I,
alkaline phosphatase determinations direct analgesic effects of these med- p 236.)
generally provide a useful, simple, ications are also important, but this

Vol 3, No 6, November/December 1995 341


Paget’s Disease of Bone

with active disease, and preparation deficits due to Paget’s disease, atten- are potent inhibitors of bone resorp-
for orthopaedic surgery (Table 3).4,15 tion to auditory acuity may be help- tion. They bind to the hydroxyap-
Before considering the use of spe- ful to detect subtle changes. 9 atite crystals in bone and may
cific therapy for Paget’s disease, a Patients with maxillary or mandibu- remain in bone for a prolonged time
thorough explanation of the disease lar involvement should be referred after the discontinuation of treat-
should be offered to the patient. for dental evaluation.9 ment.15
Treatments should be discussed in The Paget Foundation (200 Varick Etidronate disodium was the
the context of arresting progression Street, New York, NY 10014) can be original bisphosphonate approved
of the disease. In all discussions and helpful in providing patient infor- for routine clinical use. The advan-
planning, relief of pain and restora- mation on the disease. tage of this drug is that it can be
tion of function should be empha- used orally. After absorption, the
sized. The need for long-term drug localizes to bone or is
follow-up should also be stressed. Medical Treatment excreted unchanged in the urine.
All patients should be reexam- The recommended dose of etidro-
ined at least annually, and the alka- The two major types of therapeutic nate (5 mg/kg of body weight
line phosphatase level should be agents currently used in the treat- daily for 6 months) produces sup-
determined at these visits. Careful ment of symptomatic Paget’s disease pression of disease activity and
questioning, examination, and cor- are calcitonin and the bisphospho- symptoms similar to that which
relation with changes in alkaline nates.1,15 The treatment schedules occurs with calcitonin. Because
phosphatase levels will often reveal and special characteristics of each absorption of the drug is poor and
subtle symptoms and signs of dis- agent are presented in Table 4. The variable, it should be taken once
ease activity or progression that observed benefits of long-term calci- daily on an empty stomach at least
might be amenable to therapy. tonin therapy include relief of bone 2 hours remote from any other
Radiographs may be obtained peri- pain, a reduction of increased car- food; the medication may be taken
odically, as dictated by symptoms. diac output, reversal of certain neuro- with a glass of water. Etidronate
Repeat bone scans are not obtained logic deficits, stabilization of hearing should not be used in the treatment
routinely unless bone pain occurs at loss, healing of osteolytic lesions, of patients with osteolytic pagetic
a new site or new symptoms arise. and reduction in complications of lesions, for whom calcitonin is
The home environment of the orthopaedic surgery, such as exces- preferable.
patient should be discussed with the sive bleeding. Side effects appear to be less com-
goal of preventing accidents that Calcitonin is a safe and highly mon with etidronate than with calci-
could lead to pathologic fractures. effective treatment for Paget’s dis- tonin; loose bowel movements and
In patients who have auditory ease. Most patients are able to self- nausea may occur but are infrequent.
administer daily subcutaneous Hyperphosphatemia is sometimes
injections. Side effects (usually observed, particularly if higher-than-
Table 3 minor) occur in about 20% of patients recommended doses are given; the
Indications for Drug Therapy in treated with either salmon calcitonin dose should be reduced if this is
Paget’s Disease or human calcitonin. These include found. High doses or long-term
nausea, facial flushing, and polyuria. uninterrupted use also produce a
Bone pain In approximately 20% of patients, mineralization defect and might pre-
Preparation for orthopaedic resistance to chronic salmon calci- dispose to pathologic fractures.1,2,15
surgery tonin therapy develops after a suc- After the recommended 6-month
Treatment of medical complica- cessful initial treatment period. If treatment course, biochemical and
tions, including hearing loss, long-term treatment with salmon symptomatic remissions may persist
spinal stenosis with nerve calcitonin or human calcitonin is dis- for months or, occasionally, for years.
dysfunction, and high-output continued, exacerbation of biochem- In most patients, biochemical indices
congestive heart failure ical abnormalities and symptoms return toward pretreatment levels
Prevention of fracture or skeletal
may occur within 1 year.15 within a year. When symptoms
deformity in patients with
Another class of drugs useful in recur, repeat 6-month treatment
rapidly progressive osteolytic
lesions or in young patients with treating Paget’s disease is the bis- courses often will produce biochemi-
active disease phosphonates (formerly diphospho- cal and symptomatic improvement
nates). These compounds are similar to that achieved with the ini-
pyrophosphate analogues, which tial treatment course. However,

342 Journal of the American Academy of Orthopaedic Surgeons


Frederick S. Kaplan, MD, and Frederick R. Singer, MD

Table 4
Drug Treatment of Paget’s Disease

Drug Dosage Special Characteristics

Salmon calcitonin 50-100 international units subcuta- Anti–salmon calcitonin antibodies


neously daily; after symptomatic develop in 60% of patients;
improvement, may reduce to 3 clinical resistance in >20%
times weekly

Human calcitonin 0.5 mg subcutaneously daily; after Effective in salmon calcitonin–resistant


symptomatic improvement, may patients with high antibody titers
reduce to 3 times weekly

Etidronate disodium 5 mg/kg of body weight orally for Remission for years may occur after
6 months; may repeat after recur- 6 months of therapy; some patients
rence of symptoms or biochemical experience transient increased bone
exacerbation, but not sooner than pain; osteolytic lesions rarely heal;
6 months osteomalacia occurs at high doses

Pamidronate disodium 30 mg intravenously slowly over 31⁄2 New bisphosphonate with potent
to 4 hr; repeat daily for 3 consecu- antiresorption effects; transient
tive days; repeat as needed; patients fever (< 24 hr) is common side
with more severe disease may need effect
60 mg monthly or quarterly for
variable periods

resistance to repeated courses of of treatment with pamidronate can an important consideration, but
treatment is common. produce long-term remissions of the there are meager data on the man-
Second-generation bisphospho- disease. Oral preparations of some agement of this complication. Spinal
nates that are more potent than of the newer bisphosphonates will surgery should be avoided until all
etidronate have been developed. likely be available in the near future. nonsurgical options have been dili-
These agents do not impair mineral- Thus, it is likely that new-generation gently tried. Assiduous attention
ization. The most widely evaluated bisphosphonates will become the must be paid to the surgical
is pamidronate disodium,16 which most commonly used and effective approach in order to preserve spinal
has recently been approved by the therapy for Paget’s disease.16 stability.
Food and Drug Administration for Surgical intervention in Paget’s
use in Paget’s disease. The medica- disease is most often sought when
tion is administered intravenously Surgery degenerative arthritis of the hip or
because of its poor gastrointestinal knee produces severe pain on weight-
absorption. The approved treatment Some indications for surgical inter- bearing and impaired mobility.17,18
regimen is 30 mg/day by slow vention in Paget’s disease include Anti-inflammatory agents usually
(duration, 31⁄2 to 4 hours) intravenous femoral fractures and severe arthritis produce little relief of symptoms in
infusion for 3 consecutive days; the that is refractory to medical treat- this setting. Diagnostic intra-articular
regimen may be repeated as needed. ment. Malalignment of the major injections with a local anesthetic often
The drug can also be administered in weight-bearing bones or impending confirm that the pain is primarily
a 60-mg single dose or in a weekly, fractures may be treated with articular, rather than osseous. Total
monthly, or quarterly regimen, orthoses or with surgery. Preopera- hip replacement is highly effective in
depending on the severity of the dis- tive medical treatment with bisphos- relieving hip pain and restoring
ease and the response of the patient. phonates or calcitonin decreases mobility.18 Tibial osteotomy is
A brief postinfusion fever or acute intraoperative bleeding. Spinal equally effective in relieving knee
pain flare may occur. Short courses decompression for spinal stenosis is pain in patients who have severe tib-

Vol 3, No 6, November/December 1995 343


Paget’s Disease of Bone

ial bowing if the associated articular healing is planned, calcitonin and Summary
degeneration is not too advanced.19 pamidronate are the drugs of choice.
Before any operative orthopaedic When total joint replacement is Paget’s disease is a common con-
procedure is performed, it is desir- performed, long-term suppression dition in the elderly, and its com-
able, if possible, to reduce disease of disease activity through use of cal- plications are a common source of
activity with drug therapy in order citonin or pamidronate may be skeletal morbidity and symp-
to prevent excessive blood loss. A desirable to diminish excessive toms. Orthopaedic physicians
reduction in serum alkaline phos- bone-remodeling activity and pre- should be aware of the disorder
phatase activity to approximately vent loosening of prosthetic compo- and its myriad manifestations.
50% of pretreatment levels is proba- nents. 17,18 In all circumstances Although a cure is currently
bly adequate preoperative control. requiring surgery, the patient must unavailable, a wide array of med-
In elective cases, it is therefore desir- be aware that delayed bone healing ical and surgical therapeutic
able to begin antipagetic medication may occur and that a lengthy reha- options offer much hope to those
at least 6 weeks before surgery.2 bilitation program may be neces- afflicted by symptomatic compli-
When osteotomy followed by bone sary. cations.

References
1. Kaplan FS, Singer FR: Paget’s disease, 8. Ralston SH, Hoey SA, Gallacher SJ, et al: 14. Delmas PD, Gineyts E, Bertholin A, et al:
in Morley JE, Korenman SG (eds): Cytokine and growth factor expression Immunoassay of pyridinoline crosslink
Endocrinology and Metabolism in the in Paget’s disease: Analysis by reverse- excretion in normal adults and in
Elderly. Boston: Blackwell Scientific transcription/polymerase chain reac- Paget’s disease. J Bone Miner Res 1993;8:
Publications, 1992, pp 230-240. tion. Br J Rheumatol 1994;33:620-625. 643-648.
2. Merkow RL, Lane JM: Paget’s disease of 9. Kaplan FS, Haddad JG, Singer FR: 15. Bockman RS, Weinerman SA: Med-
bone. Orthop Clin North Am 1990;21:171- Paget’s disease: Complications and con- ical treatment for Paget’s disease of
189. troversies [editorial]. Calcif Tissue Int bone. Instr Course Lect 1993;42:425-
3. Siris ES, Ottman R, Flaster E, et al: 1994;55:75-78. 433.
Familial aggregation of Paget’s disease 10. Hadjipavlou A, Lander P: Paget disease 16. Siris ES: Perspectives: A practical guide
of bone. J Bone Miner Res 1991;6:495-500. of the spine. J Bone Joint Surg Am to the use of pamidronate in the treat-
4. Kaplan FS, Singer FR: Paget’s disease of 1991;73:1376-1381. ment of Paget’s disease. J Bone Miner Res
bone: Pathophysiology and diagnosis. 11. Krane SM, Kroop SF: Arthritis and 1994;9:303-304.
Instr Course Lect 1993;42:417-424. Paget’s disease of bone, in Singer FR, 17. Gabel GT, Rand JA, Sim FH: Total knee
5. Teitelbaum SL: The pathology of Wallach S (eds): Paget’s Disease of Bone: arthroplasty for osteoarthrosis in
Paget’s disease, in Singer FR, Wallach S Clinical Assessment, Present and Future patients who have Paget disease of bone
(eds): Paget’s Disease of Bone: Clinical Therapy. New York: Elsevier, 1991, pp at the knee. J Bone Joint Surg Am
Assessment, Present and Future Therapy. 191-199. 1991;73:739-744.
New York: Elsevier, 1991, pp 29-43. 12. Franck WA, Bress NM, Singer FR, et al: 18. Ludkowski P, Wilson-MacDonald J:
6. Mills BG, Singer FR: Critical evaluation Rheumatic manifestations of Paget’s Total arthroplasty in Paget’s disease of
of viral antigen data in Paget’s disease of disease of bone. Am J Med 1974;56:592- the hip: A clinical review and review of
bone. Clin Orthop 1987;217:16-25. 603. the literature. Clin Orthop 1990;255:160-
7. Hoyland JA, Freemont AJ, Sharpe PT: 13. Huvos AG, Butler A, Bretsky SS: 167.
Interleukin-6, IL-6 receptor, and IL-6 Osteogenic sarcoma associated with 19. Meyers MH, Singer FR: Osteotomy for
nuclear factor gene expression in Paget’s disease of bone: A clinicopatho- tibia vara in Paget’s disease under cover
Paget’s disease. J Bone Miner Res logic study of 65 patients. Cancer of calcitonin. J Bone Joint Surg Am
1994;9:75-80. 1983;52:1489-1495. 1978;60:810-814.

344 Journal of the American Academy of Orthopaedic Surgeons


Thoracolumbar Spine Trauma:
I. Evaluation and Classification

Jeffrey M. Spivak, MD, Alexander R. Vaccaro, MD, and Jerome M. Cotler, MD

Abstract

A timely and thorough evaluation of thoracolumbar injuries and rational treat- fluid collection, crepitus, and in-
ment based on a complete understanding of the mechanism of bone, soft-tissue, creased interspinous distance, which
and nerve injury is essential for maximizing the patient’s neurologic and func- signal injury to the posterior ele-
tional recovery and minimizing associated complications, the time to recovery, ments. Areas of localized tenderness
and the problems of long-term pain and deformity. The initial evaluation includes noted in the awake patient should be
both clinical and radiologic assessment. Clinical evaluation includes the general remembered for later scrutiny on
trauma examination as well as a detailed spinal and neurologic examination to de- radiographic examination.
termine the level (or levels) of spinal injury. Radiologic evaluation includes both
plain radiography and the appropriate use of advanced imaging modalities. A re- Neurologic Evaluation
view of the evolution of thoracolumbar injury classifications is presented. The neurologic examination for
J Am Acad Orthop Surg 1995;3:345-352 thoracolumbar trauma includes der-
matomal sensory testing, assessment
of lumbar- and sacral-root motor
function, and a detailed reflex exami-
Proper management of thoracolum- ing, circulation) evaluation that is nation (Table 1). “Spinal shock”
bar spine injuries is predicated on a standard for all trauma patients. refers to flaccid paralysis due to a
thorough understanding of the in- The spinal examination includes in- physiologic disruption of all spinal
volvement of the structural and spection and palpation of the spine cord function. This occurs commonly
neural tissues. Initial evaluation in- and a careful and complete neuro- below the anatomic level of an injury
cludes a complete and thorough logic evaluation. A high degree of to the cord. Sensory and motor func-
clinical examination. Appropriate suspicion of other injuries fre-
use of radiologic modalities pro- quently associated with thoracolum-
vides additional information, allow- bar trauma, including chest injury Dr. Spivak is Associate Chief of Spine Surgery,
ing classification of the spinal injury, and intra-abdominal injury, should Department of Orthopaedic Surgery, Hospital
assessment of spinal stability, and prompt serial chest and abdominal for Joint Diseases Orthopaedic Institute, New
York, and Assistant Professor of Orthopaedic
prognosis of recovery of neurologic examinations when significant
Surgery, New York University School of Medi-
deficits. This comprehensive initial spinal trauma is diagnosed. cine, New York. Dr. Vaccaro is Assistant Pro-
evaluation facilitates selection With a cervical collar in place and fessor, Department of Orthopaedic Surgery,
among the various surgical and non- extremity injuries splinted, the pa- Jefferson Medical College of Thomas Jefferson
surgical management options avail- tient is carefully log-rolled onto his University, Philadelphia. Dr. Cotler is Everett J.
and Marian Gordon Professor of Orthopaedic
able. or her side as a physician stabilizes
Surgery, Jefferson Medical College of Thomas Jef-
the neck in a neutral position. Abra- ferson University.
sions and deep lacerations are sug-
Initial Evaluation gestive of underlying spinal column Reprint requests: Dr. Spivak, Department of Or-
injury. Open spinal injuries are in- thopaedic Surgery, Hospital for Joint Diseases
Clinical Examination frequent but do occur, and failure to Orthopaedic Institute, 301 East 17th Street, New
York, NY 10003.
The specific directed examination diagnose an open injury due to an in-
of a patient with suspected thora- complete examination must be
Copyright 1995 by the American Academy of Or-
columbar injury begins only after avoided. Palpation of all spinous thopaedic Surgeons.
the typical “ABC” (airway, breath- processes is done, feeling for areas of

Vol 3, No 6, November/December 1995 345


Thoracolumbar Spine Trauma: I. Evaluation and Classification

common type of incomplete neuro-


Table 1 logic injury associated with injury at
Reflex Testing in Thoracolumbar Injuries the thoracolumbar junction.
An incomplete spinal cord lesion
Reflex Level Tested can be confirmed only on the basis of
sensory or voluntary motor function
Superficial abdominal (above umbilicus) T7-T10 emanating from a cord segment be-
Superficial abdominal (below umbilicus) T11-L1 low the anatomic level of injury; as
Cremasteric reflex T12-L1 defined by the American Spinal In-
Knee jerk L3-L4
jury Association, this must include
Ankle jerk S1
Anal wink S2-S4
the lowest sacral segments.1 Low
Bulbocavernosus reflex S3-S4 sacral sensation includes perianal
Plantar response Brain/cord continuity and deep anal sensation, and motor
function is tested by voluntary con-
traction of the external anal sphincter
on digital examination. For injuries
tion are absent, as are all reflexes me- reflex is the lowest cord-mediated re- at L2 and below, sacral sensory or
diated by the spinal cord levels in- flex and is therefore the first to return. motor function reflects lower motor
volved (Fig. 1). An accurate A “complete” neurologic injury is integrity, as the spinal cord termi-
assessment of the patient’s neuro- marked by a total absence of sensory nates above that anatomic level.
logic status can be made only when and motor function below the An incomplete spinal cord lesion
the patient has recovered from spinal anatomic level of injury in the ab- may follow one of four described
shock, which resolves within 48 sence of spinal shock. In an incom- classic patterns, or syndromes,
hours in more than 99% of cases. The plete neurologic lesion, residual based on the location of neural dam-
absence of spinal shock is confirmed spinal cord and/or nerve root func- age within the spinal cord (Fig. 2).
by the presence or return of cord- tion exists below the anatomic level The central cord syndrome is the
mediated reflexes below the anatomic of injury. A complete cord lesion most common incomplete spinal
area of injury. The bulbocavernosus with lumbar-root sparing is the most cord injury pattern. Since the spatial
orientation of the long tracts in the
spinal cord maintains lumbar func-
tion more centrally and sacral func-
Ascending Posterior Descending
tion more peripherally, a central
(Sensory) (Motor)
Tracts Tracts cord syndrome of the thoracolumbar
spine results in greater loss in upper
Dorsal column Lateral corticospinal lumbar motor functions (hip flexion
(position, vibration tract (voluntary and adduction and knee extension),
sense; light touch motor) with relative sparing of lower sacral
motor functions. Functional motor
recovery can be expected in 75% of
cases. In the anterior cord syn-
drome, only the dorsal columns re-
main intact, with preservation of
Lateral spinothalamic proprioception, vibration, and light
tract (pain, temperature) touch and complete loss of motor
Anterior corticospinal
function and deep pain and temper-
Anterior spinothalamic tract
ature sensation. Unfortunately, in
tract (pain, temperature)
this relatively common injury pat-
tern, functional recovery is seen in
Anterior only 10% of cases. The posterior
cord syndrome is very uncommon,
Fig. 1 Schematic drawing of a transverse section of the spinal cord at the thoracic level,
showing the anatomic organization of the corticospinal tract and the posterior column (L = with isolated loss of vibration, pro-
lumbar, S = sacral, T = thoracic). prioception, and light-touch sensa-
tion. A unilateral hemi–spinal cord

346 Journal of the American Academy of Orthopaedic Surgeons


Jeffrey M. Spivak, MD, et al

genic shock or hypovolemia due to


chest, abdominal, or extremity in-
jury with local hemorrhage. In one
series,3 neurogenic shock was the
cause of hypotension in 69% of pa-
tients with cervical spine injury. The
percentage is probably similar in pa-
tients with upper thoracic injuries.
In patients with thoracolumbar junc-
tion and lumbar injuries, however,
A B sympathetic tone is maintained to a
Ipsilateral large extent, and neurogenic shock is
Ipsilateral less common.

Radiologic Evaluation

Radiography
The radiologic evaluation of the
patient with suspected thoracolum-
Contralateral bar spine trauma begins with plain-
radiographic examination of each
C D
vertebral level (both anteroposterior
Fig. 2 Types of spinal cord injury (shaded zones) that produce the four main incomplete in- and lateral views). This complete
jury patterns seen clinically. A, Central cord syndrome. B, Anterior cord syndrome. C, Pos-
terior cord syndrome. D, Brown-Séquard syndrome.
evaluation is particularly important
in patients who cannot communi-
cate about areas of pain or who are
uncooperative because of head
injury is responsible for the Brown- upper urinary tract, and hepatic, trauma, cervical trauma with neuro-
Séquard syndrome, an uncommon splenic, and pancreatic lacerations, logic deficit, or alcohol or drug in-
injury pattern characterized by ipsi- is frequently associated with flexion- toxication.
lateral loss of motor function, light distraction injuries and fracture-dis- The chest radiograph, part of the
touch, proprioception, and vibration locations of the thoracolumbar standard trauma series, must be
sense and contralateral loss of deep junction and lumbar spine. carefully examined for evidence of
pain and temperature sense. Func- mediastinal widening. Suspicion of
tional motor recovery is seen in over Vital Signs fullness in the mediastinum must be
90% of patients with this injury pat- Hypotension in patients with evaluated with computed tomogra-
tern. multiple trauma and thoracolumbar phy (CT). An aortogram may be in-
spinal injuries is commonly due to dicated to rule out a traumatic aortic
Chest and Abdominal Examination “neurogenic shock,” a state of rela- dissection, even if thoracic spinal
The final aspect of the clinical tive hypovolemia due to a sudden trauma and paraspinal hematoma
evaluation of the thoracolumbar increase in the available circulatory are clearly visible.
trauma patient involves the exami- space caused by a loss of sympa-
nation for and recognition of associ- thetic tone in the thoracolumbar Plain Tomography and CT
ated internal injuries in the chest and region with unopposed vagal para- Computed tomography has
abdomen. Significant intrathoracic sympathetic vasodilatation. Neuro- proved invaluable in the evaluation
trauma, including hemopneumo- genic shock is characterized by of thoracolumbar injuries, especially
thorax, major vessel injury, and dia- bradycardia despite the hypoten- in assessing the integrity of the pos-
phragmatic rupture, may be seen in sion, which is also the result of un- terior aspect of the vertebral body
more than a third of patients with opposed vagal output. In patients and posterior osseous elements (Fig.
thoracic spine fractures and a neu- with hypotension and tachycardia, 3). Computed tomography is indi-
rologic deficit. 2 Intra-abdominal the physical examination should cated in all cases of suspected injury
trauma, including bowel rupture, seek another cause for the circula- to the posterior elements and poste-
major vessel injury, injuries to the tory compromise, such as cardio- rior vertebral body. Retropulsion of

Vol 3, No 6, November/December 1995 347


Thoracolumbar Spine Trauma: I. Evaluation and Classification

quent transection. Edema is seen as myelogram CT scanning is also use-


fusiform enlargement of the spinal ful in the postoperative evaluation of
cord with increased signal intensity possible persistent spinal cord com-
on T2-weighted images. Hematoma pression, especially when ferromag-
is characterized by decreased signal netic instrumentation has been used
intensity on T2 images acutely, and is posteriorly for the indirect reduction
often surrounded by a halo of T2 en- of intracanal bone fragments.
hancement from adjacent edema.
Edema extending more than two ver- Noncontiguous Spinal Injuries
tebral levels and the presence of It must be reemphasized that the
hematoma within the spinal cord are entire spine must be imaged in any
considered poor prognostic signs for patient with blunt trauma to rule out
functional motor recovery. Extrinsic additional spinal injuries that might
cord compression secondary to be unstable and that, if missed, could
Fig. 3 Transverse CT section shows bone
spinal canal compromise by osseous lead to the development or progres-
retropulsion from the posterior vertebral elements, soft tissue, or fluid collec- sion of neurologic injury. Multilevel
body of L5 into the spinal canal and a frac- tion is readily identified with MR noncontiguous spinal injuries have
ture of the lamina on the right.
imaging (Fig. 4). been reported in up to 16.7% of
Magnetic resonance imaging is cases.4-6
also useful in the evaluation of In the series of Calenoff et al,4
bone fragments into the spinal canal “spinal cord injury without radio- noncontiguous multilevel injuries
can be clearly seen on transverse sec- graphic abnormalities,” which is were found in 4.5% of cases. These
tions. Sagittal and coronal recon- more commonly seen in children. In injuries were originally missed in
structions can be very helpful in patients with this entity, as well as in 50% of those cases, with the delay in
evaluating the alignment of the patients with significant bone injury,
spinal canal. Both CT and plain to- MR imaging can be used to evaluate
mography are useful for imaging ar- the extent of intradiskal injury and
eas of suspected injury seen on plain posterior ligamentous injury. In our
films and areas not well visualized experience, true acute disk hernia-
by plain radiography, such as the tions are much less common in tho-
cervicothoracic junction. Tomogra- racolumbar injuries than in cervical
phy offers the benefit of direct imag- injuries, but are occasionally found.
ing in the sagittal and coronal The use of MR imaging for diagnosis
planes, but is becoming less and less of acute soft-tissue injury may have
available as an imaging modality. a significant impact on the decision
to perform early surgical stabiliza-
Magnetic Resonance Imaging tion. Magnetic resonance imaging
Magnetic resonance (MR) imaging may also be useful in the postinjury
provides direct visualization of the period in cases of late development
spinal cord and allows evaluation of or worsening of a preexisting neuro-
intervertebral disk trauma. It is indi- logic injury. In these clinical situa-
cated in all cases with neurologic tions, a treatable posttraumatic cyst
deficit to assess for both intrinsic and or syrinx can often be diagnosed.
extrinsic cord injuries. We also use
MR imaging for a more thorough pre- Myelography
operative evaluation of the spinal Myelography may be used for
canal in all cases in which surgical many of the same indications as MR
treatment is planned (even those in imaging, but it is invasive and does
which there is no neurologic deficit). not depict the intrinsic anatomy of Fig. 4 T2-weighted MR image demon-
strates a vertical compression injury at T8
Magnetic resonance imaging can dif- the spinal cord. It is indicated in with bone retropulsion resulting in spinal
ferentiate among the various types of cases of progressive neurologic canal compromise and spinal cord edema
intrinsic cord injuries, such as edema, deficit when MR imaging is not and compression.
hematoma, and the much less fre- available. Myelography with post-

348 Journal of the American Academy of Orthopaedic Surgeons


Jeffrey M. Spivak, MD, et al

diagnosis averaging more than 52 be in need of temporary external sta- are defined as a compression failure
days. Three common injury patterns bilization. Dislocations were also con- of the anterior column with an intact
and one subpattern were described, sidered unstable, but the ligamentous middle column and a posterior col-
which accounted for 77% of the disruption was thought to require op- umn that is intact or disrupted in
cases. Upper thoracic injuries were erative fusion for stabilization. tension. Failure of the posterior col-
found to be common among patients In 1968, Kelly and Whitesides8 umn occurs when there is more than
with multilevel noncontiguous in- put forth a two-column theory of 40% to 50% loss of anterior vertebral-
juries, occurring in 46.7% of cases. spinal stability, believing that the an- body height. In burst fractures,
In a more recent series,6 noncon- terior vertebral column provided a compression failure occurs in the an-
tiguous injuries were found in 10% of primary weight-bearing function, terior and middle columns, often
cases of spinal column injury, with while the posterior neural arch col- with retropulsion of middle-column
only 25.6% falling into the injury pat- umn primarily resisted tension (Fig. bone into the spinal canal. Seat-belt
terns described by Calenoff et al.4 5). Stability was considered to be injuries are flexion injuries about an
This series also documented a con- based on the intactness of the poste- axis near the anterior longitudinal
tinuing problem with failure of diag- rior column, which they felt was ligament, with tension failure of the
nosis of noncontiguous injuries; in strong enough to bear weight if the posterior and middle columns
31% of patients, the secondary injury anterior column was compromised. through bone or soft tissue. The an-
was missed initially, with an average terior longitudinal ligament remains
delay in diagnosis of 7.1 days. In 25% The Spine as Three Columns intact, but there may be compression
of these missed injuries, a neurologic In 1983, Denis9,10 devised a new failure of the anterior column. Frac-
deficit developed or progressed due classification of thoracolumbar in- ture-dislocations include flexion-ro-
to improper initial immobilization. juries based on a three-column the- tation, shear, and flexion-distraction
ory of spinal stability (Fig. 5). The subtypes. In each type, all three
anatomic spine was divided into columns fail in compression, ten-
Classification Schemes three sections, or columns, with sion, rotation, or shear. Vertebral
radiographs and CT scans being translation causes narrowing of the
Most patients with thoracolumbar used to assess the integrity of each. spinal canal at the site of injury and
injuries are still treated nonopera- The anterior column consists of the a high incidence of neurologic
tively with cast or brace immobiliza- anterior longitudinal ligament and deficits.
tion and early ambulation. More the anterior two thirds of the annu- Also in 1983, McAfee et al11 de-
aggressive treatment is guided by lus and vertebral body. The middle scribed a classification of six fracture
the use of classification systems that column consists of the posterior types based on the failure mode of the
detail the mechanisms of injury, the third of the vertebral body and an- middle column. Compression frac-
effects on compromised spinal struc- nulus and the posterior longitudinal tures have only anterior column com-
tures, and the potential for late me- ligament. The posterior column con- pression failure, while stable burst
chanical instability or neural injury. sists of the osseous neural arch, the fractures have both anterior- and
interspinous and supraspinous liga- middle-column compression failure.
The Spine as Two Columns ments, and the ligamentum flavum. In the unstable burst fracture, ante-
In 1963, Holdsworth7 described a On the basis of a radiographic re- rior- and middle-column compres-
mechanistic classification of thora- view, 412 thoracolumbar injuries sion failure occurs along with failure
columbar fractures, including flexion, were divided into minor and major of the posterior column, either in
flexion-rotation, extension, and com- injuries. Minor injuries, which ac- compression, lateral flexion, or rota-
pression injuries. He felt that stability counted for over 15% of fractures, in- tion. Factors such as a progressive
was based on the intactness of the cluded fractures of the spinous and neurologic deficit, progression of
“posterior ligament complex” (the transverse processes, the pars inter- kyphosis by more than 20 degrees,
supraspinous and interspinous liga- articularis, and the facet articula- more than 50% loss of vertebral body
ments, the facet joint capsule, and the tions. Major spinal injuries were height, and free bone fragments
ligamentum flavum). Wedge com- divided into compression fractures, within the spinal canal are indicative
pression fractures and compression burst fractures, seat-belt injuries, of instability in compression burst
burst fractures were considered stable and fracture-dislocations. fractures. The Chance fractures de-
injuries. Extension injuries and rota- Compression fractures repre- scribed in this system resemble the
tional fracture-dislocations were con- sented 47.8% of all thoracolumbar flexion-distraction injuries of Denis,
sidered unstable until healed and to spinal injuries in Denis’ series. They and the flexion-distraction injuries

Vol 3, No 6, November/December 1995 349


Thoracolumbar Spine Trauma: I. Evaluation and Classification

Lateral Views
Anterior Posterior Anterior Middle Posterior
column column column column column

Anterior longitudinal Ligamentum


ligament flavum

Facet joint
Intervertebral disk
Interspinous
ligament

Supraspinous
Posterior longitudinal ligament
ligament

Transverse Views

Anterior longitudinal Posterior longitudinal


ligament ligament Anterior column

Middle column
Anterior column
Posterior column
Posterior column

Facet joint

Supraspinous ligament

Fig. 5 Left, The two columns of the spine, as described by Kelly and Whitesides.8 Right, The three columns of the spine, as described by
Denis.9,10

are similar to Denis’ seat-belt injuries, In compressive flexion injuries, one series of surgically treated tho-
with compression failure of the ante- three types are described, all having racolumbar fractures, this injury
rior column and distraction failure of in common compression failure of mechanism was most common, seen
the middle and posterior columns. the anterior column. Type I injuries in 48% of cases.13
Translational injuries are failures in involve only anterior column failure Distractive flexion injuries repre-
shear or rotation, which primarily oc- in compression. Type II compres- sent tension failure of all three
cur in combination with the other in- sive flexion injuries involve com- columns due to flexion about an
jury types. pression failure of the anterior axis at or anterior to the anterior
column combined with tension fail- longitudinal ligament. This cate-
Mechanistic Classification ure of the posterior column, with the gory includes flexion-distraction
In 1984, Ferguson and Allen12 pre- axis of rotation being within the fracture-dislocations and the seat-
sented a mechanistic classification of middle column. In type III injuries, belt injuries described by Denis
thoracolumbar injuries, describing the middle column fails as well, ro- (Fig. 6, B).
seven injury patterns. This system tating back into the spinal canal due Lateral flexion injuries are seen in
categorizes injuries by the forces that to either tension or “hydraulic two patterns, the first being unilat-
create them and is therefore useful in blowout” (Fig. 6, A). With this eral compression failure of the ante-
guiding nonoperative and operative mechanism, the middle-column rior and middle elements. In the
stabilization. height is maintained or increased. In second pattern, the posterior ele-

350 Journal of the American Academy of Orthopaedic Surgeons


Jeffrey M. Spivak, MD, et al

A B C

Fig. 6 Lateral injury radiographs. A, Ferguson-Allen type III compressive flexion injury. B, Distractive flexion injury. C, Translational in-
jury (primarily anteroposterior translation in combination with

ments are disrupted as well, with ip- bony elements may also fail in com- mal canal compromise at the level of
silateral compression failure and pression. the bony posterior neural arch.
contralateral tension failure, includ- Distractive extension, the final in-
ing unilateral facet dislocations. jury mechanism, is rare in the thora-
Translational injuries are the re- columbar spine. This mechanism is Summary
sult of anterior-posterior or lateral characterized by tension failure of
shear forces. They are uncommon as the anterior column and compres- Successful management of thora-
isolated injuries but are often associ- sion failure of the posterior elements. columbar spine injuries depends on a
ated with other injury mechanisms thorough knowledge of spinal anat-
(Fig. 6, C). In torsional flexion in- Neurologic Injury and Recovery omy and an understanding of the in-
juries, the anterior column fails in In 1988, Dall and Stauffer14 classi- jury mechanism and the resultant
compression and rotation, and the fied burst fractures of the thora- compromise of bone and soft-tissue
posterior elements fail in tension columbar junction by the degree of structures. A complete classification
and rotation, commonly with mid- regional kyphosis and the location of scheme for thoracolumbar fractures
dle-column involvement as well. maximal canal compromise in order that incorporates the mechanism of
These and translational injuries are to correlate fracture pattern with injury, a description of osseous and
the most unstable thoracolumbar in- neurologic injury and recovery. The ligamentous destruction, and the de-
juries and have the highest propen- severity of neurologic injury did not gree of neurologic damage is still
sity to cause paraplegia. correlate with the fracture pattern or lacking. Such a classification system
Vertical compression injuries are the amount of spinal canal compro- would enable the treating physician
characterized by anterior- and mid- mise. Neurologic recovery was to identify an unstable thoracolum-
dle-column compression failure greatest in patients with more than bar injury, make a prognosis as to
with vertebral-body shortening. 15 degrees of initial kyphosis and neurologic recovery, and direct the
Middle-column failure is osseous, least in patients with less than 15 de- choice of nonoperative or operative
not ligamentous, and the posterior grees of initial kyphosis and maxi- management.

Vol 3, No 6, November/December 1995 351


Thoracolumbar Spine Trauma: I. Evaluation and Classification

References
1. Ditunno JF Jr (ed): International Stan- 5. Henderson RL, Reid DC, Saboe LA: 11. McAfee PC, Yuan HA, Fredrickson
dards for Neurological and Functional Clas- Multiple noncontiguous spine fractures. BE, et al: The value of computed to-
sification of Spinal Cord Injury. Chicago: Spine 1991;16:128-131. mography in thoracolumbar frac-
American Spinal Injury Association, 6. Vaccaro AR, An HS, Lin S, et al: Non- tures: An analysis of one hundred
1992. contiguous injuries of the spine. J Spinal consecutive cases and a new classifi-
2. Bohlman HH, Freehafer A, Dejak J: Disord 1992;5:320-329. cation. J Bone Joint Surg Am 1983;65:
The results of treatment of acute in- 7. Holdsworth FW: Fractures, disloca- 461-473.
juries of the upper thoracic spine with tions, and fracture-dislocations of the 12. Ferguson RL, Allen BL Jr: A mechanis-
paralysis. J Bone Joint Surg Am 1985;67: spine. J Bone Joint Surg Br 1963;45:6-20. tic classification of thoracolumbar
360-369. 8. Kelly RP, Whitesides TE Jr: Treatment spine fractures. Clin Orthop 1984;189:
3. Soderstrom CA, McArdle DQ, Ducker of lumbodorsal fracture-dislocations. 77-88.
TB, et al: The diagnosis of intra-ab- Ann Surg 1968;167:705-717. 13. Cotler JM, Vernace JV, Michalski JA:
dominal injury in patients with cervical 9. Denis F: The three column spine and its The use of Harrington rods in thora-
cord trauma. J Trauma 1983;23:1061- significance in the classification of acute columbar fractures. Orthop Clin North
1065. thoracolumbar spinal injuries. Spine Am 1986;17:87-103.
4. Calenoff L, Chessare JW, Rogers LF, et 1983;8:817-831. 14. Dall BE, Stauffer ES: Neurologic injury
al: Multiple level spinal injuries: Impor- 10. Denis F: Spinal instability as defined by and recovery patterns in burst fractures
tance of early recognition. AJR Am J the three-column spine concept in acute at the T12 or L1 motion segment. Clin
Roentgenol 1978;130:665-669. spinal trauma. Clin Orthop 1984;189:65-76. Orthop 1988;233:171-176.

352 Journal of the American Academy of Orthopaedic Surgeons


Thoracolumbar Spine Trauma:
II. Principles of Management

Jeffrey M. Spivak, MD, Alexander R. Vaccaro, MD, and Jerome M. Cotler, MD

Abstract

The care of patients with thoracolumbar spine trauma with or without neurologic or preventing the secondary cord in-
deficits has evolved dramatically over the past 20 years with the emergence of ter- jury caused by edema and ischemia.
tiary-care spinal injury centers and the development of more effective spinal in- Intravenous methylprednisolone is
strumentation and anesthesia techniques. Despite these advances, the majority of routinely administered in all cases of
patients with thoracolumbar injuries are still treated nonoperatively with cast or blunt spinal cord injury, in accor-
brace immobilization and early ambulation. More aggressive treatment is guided dance with the protocol established
by the use of classification systems that detail the mechanism of injury, the degree by Bracken et al1 (bolus of 30 mg/kg
of compromise of spinal structures, and the potential for late mechanical instabil- of body weight, followed by 5.4
ity or neural injury. The goal of treatment remains attainment of spinal stability mg/kg/hr by continuous infusion
with protection or improvement of the patient’s neurologic status, allowing rapid for a total of 23 hours). Its efficacy
and maximal functional recovery. has been established only in situa-
J Am Acad Orthop Surg 1995;3:353-360 tions in which treatment is started
within 8 hours of injury and in cases
of blunt spinal cord injury. The effi-
cacy of corticosteroid use has not
There are a variety of issues to be rolling of the patient or miscommu- been shown for pure root injuries.
considered in the management of nication concerning the patient’s The complications of steroid use, in-
patients with thoracolumbar spine spinal stability and activity level. An cluding a higher rate of postopera-
trauma. Initial management issues oscillating bed is useful for shifting tive infection and gastric ulcers,
include immobilization, medical sta- the patient’s body weight without
bilization, and achievement of spinal moving the patient. If traction is
alignment. Definitive management deemed desirable, this is an effective
decisions are based on spinal stabil- means of providing spinal immobi- Dr. Spivak is Associate Chief of Spine Surgery,
ity at the injury site and the need for lization. Department of Orthopaedic Surgery, Hospital
decompression of neural elements, for Joint Diseases Orthopaedic Institute, New
followed by appropriate rehabilita- York, and Assistant Professor of Orthopaedic
tion to maximize the patient’s func- Medical Stabilization Surgery, New York University School of Medi-
cine, New York. Dr. Vaccaro is Assistant Pro-
tional outcome. fessor, Department of Orthopaedic Surgery,
Medical stabilization of the trauma Jefferson Medical College of Thomas Jefferson
patient with a thoracolumbar injury University, Philadelphia. Dr. Cotler is Everett J.
Immobilization is of paramount importance. Hy- and Marian Gordon Professor of Orthopaedic
potension secondary to neurogenic Surgery, Jefferson Medical College of Thomas Jef-
ferson University.
Immobilization has been shown ex- shock or hemorrhagic shock must be
perimentally to help limit further reversed through fluid and/or Reprint requests: Dr. Spivak, Department of Or-
damage to the injured spinal cord blood replacement, with or without thopaedic Surgery, Hospital for Joint Diseases
and is often beneficial in controlling the use of vasopressors. Critical or- Orthopaedic Institute, 301 East 17th Street, New
the pain associated with a spinal col- gan systems must be evaluated and York, NY 10003.
umn injury. Simple bed rest with treated as needed.
log-rolling can be used, but prob- Medical treatment of the injured Copyright 1995 by the American Academy of Or-
thopaedic Surgeons.
lems may occur with improper log- spinal cord is directed at minimizing

Vol 3, No 6, November/December 1995 353


Thoracolumbar Spine Trauma: II. Principles of Management

must be considered. Although the the desire is to improve anterior ver- clude burst fractures without neuro-
study by Bracken et al has been crit- tebral column height and reduce the logic deficit, in which the late onset
icized for methodologic flaws, their degree of kyphosis, Gardner-Wells of neurologic deficits is sometimes
protocol is currently considered by tong–bifemoral skeletal traction may seen. The most unstable injuries,
many to be the standard of care in be a useful adjunct. This form of im- those characterized by mechanical
acute spinal cord injury and should mobilization certainly ensures pa- and neurologic instability, include
be followed. Newer pharmacologic tient compliance in terms of bed rest. burst fractures with neurologic
agents, such as b-glycosides and The skin beneath any padded bolster deficit and fracture dislocations.
growth factors, are currently being must be examined daily for evidence White and Panjabi5 have devised
evaluated prospectively in major of skin breakdown, which could sig- a clinical checklist for thoracic and
spinal cord injury centers. nificantly compromise a posterior lumbar instability. In their system,
Thromboembolic disease remains surgical site. they consider radiographic criteria
a considerable problem in acutely (subluxation, segmental angulation)
traumatized patients, and patients and the degree of neural injury, as
with spinal injuries are no excep- Evaluation of Spinal well as anticipated dangerous load-
tion.2 We aggressively employ me- Stability ing, to determine the degree of
chanical prophylaxis (intermittent spinal instability.
external pneumatic compression de- In determining the optimal treat- At our institutions, we use Denis’
vices) for lower-extremity deep-vein ment in cases of spine trauma, the definition as a broad guideline for
thrombosis and the more serious stability of the particular spinal in- the assessment of stability of a thora-
pulmonary embolism in all cases of jury must be carefully assessed fol- columbar injury. Spinal injuries
significant spinal trauma. Routine lowing a complete clinical and with any associated neurologic
prophylaxis also includes subcuta- radiographic evaluation. In the deficit are considered to be unstable.
neous heparin in a dosage of 5,000 most general sense, the spinal col- These injuries usually require opera-
units every 12 hours. The use of in- umn is considered stable if it is able tive stabilization to adequately im-
travenous low-molecular-weight to withstand normally applied phys- mobilize the injured segments and
heparin is currently being investi- iologic loads without the develop- protect the injured and at-risk neu-
gated. Deep-vein thrombosis is di- ment of neural irritation or damage, rologic structures.
agnosed with the use of real-time unacceptable deformity, or chronic
B-mode ultrasonography. Venogra- pain due to abnormal motion.
phy is used if the ultrasound results Early reports assessing the degree Nonoperative Treatment
are unclear. The presence of pul- of spinal stability focused on the in-
monary embolism is assessed with tegrity of the posterior elements. Nonoperative treatment in thora-
ventilation-perfusion scanning and, More recent analysis considers the columbar trauma is reserved for
if needed, pulmonary angiography. degree of osseous and ligamentous those injuries that are considered to
Treatment includes heparin or war- destruction in conjunction with the be stable without the potential for
farin if the patient clearly does not degree of canal compromise, defor- progressive deformity or neural
have an operative problem. If mity, and neurologic deficit. compression with ambulatory treat-
surgery is required, the thromboem- In 1983, Denis used computed to- ment and external immobilization.
bolic problem is treated by percuta- mographic analysis of thoracolum- In 1992, Gertzbein6 reported the
neous placement of an inferior vena bar fractures and dislocations in the findings from the Scoliosis Research
cava filter. development of the three-column Society multicenter prospective
theory of spinal stability,3,4 as de- study of 1,109 patients with spinal
scribed in the accompanying article. fractures. At the 2-year follow-up,
Alignment The spine is considered to be un- patients with a kyphotic deformity
stable if two or more columns are of more than 30 degrees had an in-
Various means have been employed injured. Denis described three creased incidence of significant back
to improve spinal alignment in the categories of instability. Mechanical pain.
peri-injury period. Postural reduc- instability includes severe compres- One-column injuries are stable by
tion with simple bed rest and place- sion fractures, in which posterior el- definition; these include wedge
ment of a small padded bolster at the ements are injured in distraction and compression fractures and fractures
apex of a spinal deformity may be ef- late kyphotic collapse is possible. of the posterior elements. These in-
fective in certain injury patterns. If Cases of neurologic instability in- juries will heal well when treated in

354 Journal of the American Academy of Orthopaedic Surgeons


Jeffrey M. Spivak, MD, et al

an ambulatory fashion with external cases and that late neurologic modeling of retropulsed bone frag-
immobilization by means of a plas- deficits, bone deformity, and insta- ments.
ter cast or orthosis. The form of im- bility can be corrected if they occur. Decompression of the spinal col-
mobilization chosen should provide We agree with others who believe umn can be done via an anterior, a
a force vector opposite to the initial that surgical stabilization facilitates posterolateral, or a posterior ap-
major injury force, such as an exten- the most rapid functional return and proach. Anterior decompression
sion cast or an orthosis for a com- reintegration into society for pa- by means of a vertebrectomy is use-
pressive flexion injury. For injuries tients with unstable fractures. This ful for spinal canal compromise
above T7, an occipitocervicothoracic approach also prevents the late com- due to retropulsion of bone and
orthosis is used until healing, which plications of neurologic injury, de- disk fragments from the middle col-
is expected in 8 to 12 weeks. For le- formity, and painful instability. The umn in the thoracic spine and tho-
sions at T7 or below, a thoracolum- surgical methods needed to correct racolumbar junction. The vertebral
bosacral orthosis is prescribed, and the sequelae of late instability and body is commonly reconstructed
healing is expected in 12 to 16 weeks. fixed deformity are quite complex with the use of an autogenous ante-
In low lumbar injuries, the cast or and fraught with significant mor- rior iliac-crest strut graft. Anterior
orthosis should include one thigh for bidity. decompression and vertebral re-
the first 6 to 12 weeks in order to sta- In cases of middle-column dis- construction require additional
bilize the pelvis. ruption, decompression of persis- stabilization, which can be accom-
Nonoperative treatment is also an tent spinal canal compromise is plished by means of external
option for certain isolated injuries often indicated, even in the presence immobilization, anterior instru-
with bone instability and no neuro- of complete neurologic lesions, in mentation, or posterior instrumen-
logic deficits. For example, flexion- the hope of additional root recovery. tation and fusion.
distraction injuries through bone This is most important in the case of Posterolateral decompression in
(Chance fractures) will heal when trauma at the thoracolumbar junc- the thoracolumbar spine can be per-
immobilized in an extension cast or tion and in the upper lumbar spine, formed with the use of a modified
a custom-molded orthosis. Certain where recovery of an additional root costotransversectomy approach by
vertical compression fractures (sta- level may have tremendous func- removal of the transverse process
ble burst fractures) with minimal or tional significance. and pedicle. Although posterior
no middle-column comminution or spinal stabilization can be per-
shortening and minimal kyphosis Decompression formed through the same incision,
can also be treated in an extension Spinal canal intrusion by bone or structural grafting of the anterior
cast or a custom-molded brace. soft-tissue fragments may require column is difficult via this approach
surgical decompression. Most often, because of the limited exposure.
compression occurs anteriorly in the Another method of posterolateral
Operative Treatment spinal canal due to retropulsion of decompression that can be em-
bone or disk fragments from the mid- ployed at the level of the conus
Surgical Indications dle column. Posterior compression medullaris involves removing the
Operative management of thora- by lamina fragments can also occur. medial half of the pedicle at the level
columbar injuries is indicated for le- In cases of significant spinal canal of injury, undercutting anterior to
sions that are considered to be compromise with an incomplete neuro- the retropulsed fragment, and im-
unstable and to have the potential logic deficit, persistent neural com- pacting the fragment back into the
for further compromise to the neuro- pression should be assumed to vertebra without retraction of the
logic elements. Even in patients necessitate spinal decompression. In dura. We have no experience with
with complete neurologic lesions, the case of complete lesions of the this technique and prefer anterior
surgical stabilization can allow more thoracolumbar junction and lumbar decompression in these situations
rapid mobilization and earlier com- spine, additional root recovery may for more complete visualization of
mencement of physical rehabilita- provide important functional bene- the compressed dural sac.
tion. Controversy exists as to the fits; decompression may be indicated Posterior decompression of the
treatment of unstable spinal column if significant canal compromise ex- retropulsed middle column can be
injuries in patients without neuro- ists. In cases without neurologic done either directly or indirectly.
logic injury. Proponents of initial deficit, canal decompression may not We use direct posterior decompres-
nonoperative treatment believe that be indicated as long as spinal stability sion only below the conus medul-
good results can be obtained in most can be ensured due to eventual re- laris in the region of the cauda

Vol 3, No 6, November/December 1995 355


Thoracolumbar Spine Trauma: II. Principles of Management

equina. Retraction of the dural sac done on an urgent, not emergent, ba- needed. In cases of posterior stabi-
may be necessary for direct posterior sis. Patients are medically stabilized lization after anterior decompres-
decompression; this can cause dam- as active fracture bleeding abates, sion and strut-graft stabilization of
age to the spinal cord and conus and hematoma is allowed to form, the anterior and middle columns,
medullaris. The safe region is typi- minimizing surgical blood loss, es- compression instrumentation cre-
cally at the level of L2 and more cau- pecially with anterior decompres- ates the most stable overall con-
dally. This can be easily confirmed sive procedures. The only emergent struct.
with a preoperative magnetic reso- indications for surgery in cases of
nance imaging study. thoracolumbar trauma are a pro- Treatment of Specific Injuries
Indirect posterior decompression gressive neurologic deficit and an
through the use of distraction and incomplete neurologic deficit associ- Middle-Column Disruption With
lordosis forces can be useful in the ated with an irreducible dislocation, Canal Compromise
thoracic spine and at the thora- both of which are uncommon. No We agree with others that ante-
columbar junction. Distraction in- studies have documented improved rior decompression is the most reli-
strumentation has been shown to be neurologic outcomes with emergent able method of achieving a complete
effective in reducing retropulsed stabilization of unstable thora- decompression and is preferred for
middle-column fragments in the columbar injuries with or without cases of anterior canal compromise
spinal canal, especially when done neural decompression. Studies have with incomplete neurologic deficits.
within 2 days of injury. Transpe- shown, however, that even late de- Direct posterior decompression is
dicular screw constructs that allow compression of persistent thora- used for injuries below the conus
distraction and lordosing force ap- columbar spinal cord compression medullaris. In cases without neuro-
plications can also be used for indi- can be beneficial in terms of im- logic deficit in which stabilization is
rect canal decompression. It has proved neurologic status.8 required, indirect posterior decom-
been shown experimentally that in- pression is performed. In cases of
direct reduction results from the in- Posterior Instrumentation complete injury, if one is attempting
sertion of the posterior annulus The choice of posterior instru- decompression for added functional
fibrosus into the superior vertebral mentation and the selection of the root recovery, we prefer either ante-
endplate, not the posterior longitu- method of application are based on a rior decompression at or above the
dinal ligament.7 Distraction, not lor- number of factors. The mechanism conus level or direct posterior de-
dosis, was shown to be the major of injury and the resultant fracture compression below the conus level;
reduction force, and a combination pattern determine the force applica- if not, stabilization is accomplished
of distraction and lordosis was tion that must be supplied by the in- posteriorly, with indirect reduction
found to provide the optimal indi- strumentation system. In general, of the spinal canal.
rect reduction forces necessary for distraction instrumentation is used After anterior decompression, we
spinal realignment. for compression injuries with intact utilize an autologous tricortical ante-
Laminectomy alone as a decom- posterior elements. Distraction and rior iliac-crest strut graft, placed be-
pressive procedure has been shown lordosing constructs are also useful tween the superior endplate of the
to be ineffective in alleviating ante- for indirect decompression of spinal vertebral body above and the infe-
rior spinal canal compression. canal compromise due to middle- rior endplate of the vertebral body
Laminectomy is indicated in pa- column compression. Distraction below, with the anterior column un-
tients with neurologic deficits and can be achieved with either hook, der distraction. This is followed by
laminar fractures, to allow inspec- pedicle-screw, or hybrid constructs posterior fusion with compression
tion for trapped neural elements and connecting longitudinal rods. Com- instrumentation with use of a rod-
dural tears. In all cases in which a pression constructs are used for flex- hook system or a rigid pedicle
laminectomy is performed, the ion-distraction injuries if the middle screw-rod construct.
spinal column is further destabi- column is not comminuted and the Anterior instrumentation systems
lized, and fusion with instrumenta- facets are intact. Segmental stabi- can obviate the need for posterior
tion is mandatory. lization with hooks, sublaminar surgery. While certain older anterior
wires, and transpedicular screws is systems were associated with late in-
Timing of Surgery used in the highly unstable flexion- jury to the great vessels, newer sys-
We believe that surgical decom- rotation and translational injuries tems present a lower profile and are
pression, if needed, and stabilization and can be used in conjunction with placed along the lateral aspect of the
of thoracolumbar injuries should be compression or distraction forces if vertebral body. These have been

356 Journal of the American Academy of Orthopaedic Surgeons


Jeffrey M. Spivak, MD, et al

used safely to stabilize vertebral re- might be particularly useful in pa- and distraction rods with supple-
constructions for trauma and tumor tients with neural deficits and only a mental segmental fixation.
surgery. If anterior instrumentation small amount of anterior compres- Ferguson-Allen type III compres-
is used, the bone graft is sized to fit sion, in whom occult neural injury sive flexion injuries with significant
between the inferior endplate of the secondary to laminar entrapment is canal compromise and an incom-
cranial vertebra and the superior more likely. plete neural deficit are treated by
endplate of the caudal vertebra, to al- one-stage anterior decompressive
low fixation into undisturbed verte- Thoracic Spine (T1-T10) vertebrectomy and autologous iliac-
bral bone. We remain reluctant to In the thoracic spine, we treat Fer- crest strut grafting followed by pos-
use hardware anteriorly at L5 and guson-Allen type I compressive flex- terior compression instrumentation
the sacrum, because of the potential ion injuries10 with an extension cast and fusion. The posterior instru-
for late injury to the great vessels. and early ambulation. Type II and mentation incorporates only the
type III compressive flexion injuries motion segments involving the strut
Middle-Column Disruption and with or without neurologic deficit graft, provided the hooks are placed
Posterior-Element Fractures are generally stabilized with seg- out of the zone of spinal cord injury.
Posterior surgery is an integral mental instrumentation with the use Anterior instrumentation is an ac-
part of the operative treatment of of a hook-and-rod construct. In the ceptable fixation alternative.
vertical compression or burst frac- presence of a complete spinal cord Translational and rotational in-
tures with associated laminar frac- injury, sublaminar wires can be uti- juries are highly unstable and require
tures and neurologic deficits. A lized in addition to a hook-rod con- posterior segmental instrumentation.
number of reports have documented struct. Alternatively, one may use In most cases, patients have complete
dural tears and entrapment of neural an inexpensive rectangular Luque neurologic injuries but will benefit
elements with laminar fractures. It is rod with sublaminar wires (Fig. 1). from early stabilization and mobiliza-
hypothesized that the initial splay- The Luque rectangle is prebent in tion. Following postural reduction,
ing of the pedicles and the posterior- mild hypokyphosis to reduce the fixation is achieved with hook and/or
element displacement are followed segmental kyphosis at the level of in- sublaminar wire constructs, as de-
by the recoiling to the stable position jury. The instrumentation generally scribed for the severe compressive
that is seen on radiographic evalua- incorporates three levels above and flexion injuries.
tion.9 The dura and neural elements two to three levels below the injury.
become trapped within the frac- Other acceptable instrumentation Thoracolumbar Junction (T11-L2)
tured posterior elements and injured constructs include standard Luque Ferguson-Allen type II compres-
during the recoil. Recognition of rods with spinous-process wiring sive flexion injuries of the thora-
trapped neural elements and their
decompression can be accomplished
only through posterior exploration.
Special care must be taken during
the approach. Because the dura and
neural elements can be encountered Fig. 1 Anteroposterior (A)
before reaching the lamina, expo- and lateral (B) radiographs
show successful fusion fol-
sure of the lamina above and below lowing operative treatment
the injury level is done first. The in- of an unstable T6 fracture in
jury level is then exposed by careful a patient with a complete
spinal cord injury. A Luque
blunt dissection. Visualization of rectangle was used, with
the dura or nerve roots is an indica- sublaminar wire fixation of
tion for hemilaminectomy to explore three intact levels above and
three intact levels below the
the surrounding dura for tears, injury site. Additional non-
which are repaired if possible. instrumented levels within
Hemilaminectomy and explo- the construct had posterior
element fractures.
ration may also benefit patients with
laminar fractures without posteri-
orly visible neural elements, as
neural entrapment along the anterior A B
aspect of the lamina is possible. This

Vol 3, No 6, November/December 1995 357


Thoracolumbar Spine Trauma: II. Principles of Management

columbar junction are treated by pos- tion, which is a less stable construct Distractive flexion injuries are
terior compression instrumentation, than posterior compression instru- treated by reduction and compression
with the intact middle column being mentation. instrumentation, as described previ-
used as a hinge to restore lordosis. In vertical compression injuries ously. Lateral flexion injuries can be
Type III injuries without significant with compromise of the anterior and treated with combined ipsilateral dis-
canal compromise are treated with middle columns, the decision for sur- traction and contralateral compres-
the use of distraction-lordosis instru- gical stabilization rests on the integrity sion, applied with the use of hooks or
mentation to maintain the middle- of the posterior ligament-bone com- transpedicular screws above and be-
column height and restore the plex. If the posterior elements are in- low the level of injury. The compres-
anterior-column height. Care must tact without significant kyphosis (less sion force is applied first, to improve
be taken to avoid overdistraction in than 20 degrees) or anterior loss of ver- the lordosis and prevent kyphosis
patients with concomitant posterior- tebral body height (less than 50%), am- from the distraction force.
column tension injuries. Caution bulatory nonoperative treatment with Translational and torsional flex-
must be exercised if one chooses to an extension body cast or custom- ion injuries are treated by segmental
use short-segment pedicle-screw sta- molded extension thoracolumbo- instrumentation, preferably with
bilization in cases of anterior- and sacral orthosis can be used (usually pedicle screws. Hook constructs
middle-column compromise. High including a single thigh cuff). We gen- and screw-hook combination con-
fixation failure rates have been re- erally stabilize vertical compression structs can also be used.
ported in these clinical situations.11 injuries with three-column involve-
We have utilized this form of treat- ment posteriorly. Patients with ante- Low Lumbar Injuries (L3-L5)
ment with postoperative immobiliza- rior thecal sac compression and an Compressive flexion and vertical
tion in a hyperextension plaster body incomplete neurologic deficit, regard- compression injuries of the low
cast for a minimum of 3 months and less of the integrity of the posterior el- lumbar spine are managed by
have found fewer instrumentation ements, are treated operatively by transpedicular screw instrumenta-
failures than reported. A custom- one-stage anterior vertebrectomy and tion, fusing one level above and one
molded thoracolumbosacral orthosis strut grafting followed by posterior level below the injury (Fig. 3). Cau-
may also be acceptable for postoper- compression instrumentation (Fig. 2). tion must be exercised with the use of
ative immobilization, but we have Anterior decompression followed by short-segment instrumentation
no experience with it in this clinical anterior instrumentation is certainly when there is loss of anterior- or mid-
setting. an acceptable option. dle-column support, because of the
In cases of significant canal com-
promise and incomplete or complete
neurologic injury, we prefer anterior
decompression by means of vertebral
corpectomy and autologous iliac-crest
strut grafting, followed by posterior
compression instrumentation with the Fig. 2 Anteroposterior (A)
use of hooks or transpedicular screws. and lateral (B) radiographs
Acceptable alternative treatment op- obtained after surgical treat-
ment of a patient with an in-
tions include (1) anterior decompres- complete neurologic deficit
sion with reconstruction and anterior and significant bony canal
internal fixation and (2) posterior fixa- compromise after a Fergu-
son-Allen type III compres-
tion and indirect reduction followed sive flexion injury. The
by postoperative examination of the procedure involved a one-
spinal canal with myelography or stage anterior L1 corpectomy
with autogenous iliac-crest
computed tomography and second- strut grafting and posterior
stage anterior decompression and ver- T12-L2 fusion with compres-
tebral reconstruction if significant sion-rod instrumentation.
canal compromise and neurologic
deficit persist. One objection we have
to the latter approach is that an ante-
rior structural bone graft is supported A B
by posterior distraction instrumenta-

358 Journal of the American Academy of Orthopaedic Surgeons


Jeffrey M. Spivak, MD, et al

Rehabilitation
Fig. 3 Anteroposterior (A) In patients with a residual neuro-
and lateral (B) radiographs
obtained after operative logic deficit, passive motion exer-
treatment of an L5 vertical cises and splinting are useful in the
compression injury in a 21- early postinjury period to maintain
year-old man with a partial
neurologic deficit. The opera- joint flexibility and maximize func-
tive procedure included L5 tional potential. Upper-body
laminectomy and direct poste- strength training is essential for
rior decompression and stabi-
lization with pedicle-screw functional paraplegic patients to fa-
fixation, with which mild dis- cilitate self-transfers and a return to
traction and lordosis forces independence in society. The appli-
were applied. Postopera-
tively, the patient was allowed cation and use of orthotic devices
to ambulate in a body cast, with appropriate training can allow
molded in extension and in- independent ambulation by patients
corporating a thigh segment.
with functional motor strength at
A B low lumbar levels. Assistive devices
and vocational retraining help the
patient to regain maximal functional
and financial independence.
potential for screw failure. Trans- traction-rod instrumentation is less
pedicular bone grafting of the in- desirable in this region because of the
jured level may be of benefit, but we associated loss of lordosis and the Summary
have no experience with this tech- need to instrument additional levels
nique. If decompression is needed, above and below the injury site. Successful management of thora-
we prefer the posterior direct tech- Translational and flexion-rotation columbar spine injuries protects
nique via laminotomy, although an- injuries in the low lumbar spine also the patient from further spinal de-
terior decompression can be done as require segmental instrumentation. formity and neurologic deficit. The
well. Decompression should be con- This is easily accomplished by majority of patients with thora-
sidered even for complete neurologic transpedicular screw fixation one columbar injuries are still treated
lesions, to allow for possible addi- level above and one level below the nonoperatively with cast or brace
tional lumbosacral root return. Dis- injury (Fig. 4). immobilization and early ambula-
tion. There is no clear consensus as
to the absolute indications for surgi-
cal intervention in patients with
many types of thoracolumbar frac-
tures. Opinions vary most in cases
of complete spinal cord injury or no
neurologic deficit at all. Operative
treatment, including both decom-
Fig. 4 Anteroposterior (A) pression and stabilization, is more
and lateral (B) radiographs
show segmental transpedic- universally accepted in cases of in-
ular instrumentation of a complete spinal cord injury with
highly unstable translational radiographic evidence of persistent
injury after postural reduc-
tion. (This is the same injury mechanical compression of the
seen in Figure 6, C, in the ac- neural structures. Controlled
companying article.) prospective studies evaluating con-
temporary classification systems
and recommended treatment pro-
tocols (both nonoperative and op-
erative) are necessary to better
define the role of surgical interven-
A B tion in these potentially devastat-
ing injuries.

Vol 3, No 6, November/December 1995 359


Thoracolumbar Spine Trauma: II. Principles of Management

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360 Journal of the American Academy of Orthopaedic Surgeons