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 American Academy of Orthopaedic Surgeons
American Academy of Pediatrics

Essentials of
Musculoskeletal
Care
April D. Armstrong, BSc(PT), MSc, MD, FRCSC
Mark C. Hubbard, MPT
Editors
 Board of Directors, 2015-2016
Published 2016 by the
David D. Teuscher, MD
American Academy of Orthopaedic Surgeons
President
9400 West Higgins Road
Gerald R. Williams, Jr, MD Rosemont, IL 60018
First Vice President
William J. Maloney, MD Fifth Edition
Second Vice President Copyright 2016
Frederick M. Azar, MD by the American Academy of Orthopaedic Surgeons
Treasurer
Frederick M. Azar, MD The material presented in Essentials of Musculoskeletal Care, 5th Edition
Past President has been made available by the American Academy of Orthopaedic
Lisa K. Cannada, MD Surgeons for educational purposes only. This material is not intended
Howard R. Epps, MD
to present the only, or necessarily best, methods or procedures for the
medical situations discussed, but rather is intended to represent an
Daniel C. Farber, MD
approach, view, statement, or opinion of the author(s) or producer(s),
Daniel K. Guy, MD which may be helpful to others who face similar situations.
Lawrence S. Halperin, MD
David A. Halsey, MD Some drugs or medical devices demonstrated in Academy courses or
David J. Mansfield, MD described in Academy print or electronic publications have not been
cleared by the Food and Drug Administration (FDA) or have been cleared
Raj D. Rao, MD
for specific uses only. The FDA has stated that it is the responsibility
Brian G. Smith, MD of the physician to determine the FDA clearance status of each drug or
Ken Sowards, MBA device he or she wishes to use in clinical practice.
Jennifer M. Weiss, MD
Karen L. Hackett, FACHE, CAE (ex officio) Furthermore, any statements about commercial products are solely the
opinion(s) of the author(s) and do not represent an Academy endorsement
Staff or evaluation of these products. These statements may not be used in
Ellen C. Moore, Chief Education Officer advertising or for any commercial purpose.
Hans Koelsch, PhD, Director, Department of
All rights reserved. No part of this publication may be reproduced, stored
Publications
in a retrieval system, or transmitted, in any form, or by any means,
Lisa Claxton Moore, Senior Manager, Book electronic, mechanical, photocopying, recording, or otherwise, without
Program
prior written permission from the publisher.
Laura Goetz, Managing Editor
Steven Kellert, Senior Editor Library of Congress Control Number: 2015945905
Michelle Wild, Associate Senior Editor
Courtney Dunker, Editorial Production Manager ISBN 978-1-62552-415-7
Abram Fassler, Publishing Systems Manager Printed in the USA
Suzanne O’Reilly, Graphic Designer
Susan Morritz Baim, Production Coordinator Cover art
Karen Danca, Permissions Coordinator Robert Liberace
Charlie Baldwin, Digital and Print
Production Specialist Anatomic Illustrations
Scott Thorn Barrows, MA, CMI, FAMI
Hollie Muir, Digital and Print Production
Specialist
Emily Nickel, Page Production Assistant
Genevieve Charet, Publications Assistant
Brian Moore, Manager, Electronic Media
Programs
Katie Hovany, Digital Media Specialist

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 iii

 Essentials of Musculoskeletal Care, 5th Edition
Editorial Board
April D. Armstrong, BSc(PT), MSc, MD, FRCSC
Professor, Chief Shoulder and Elbow Surgery
Bone and Joint Institute
Penn State Milton S. Hershey Medical Center
Hershey, Pennsylvania

Mark C. Hubbard, MPT

Physical Therapist
Bone and Joint Institute
Penn State Milton S. Hershey Medical Center
Hershey, Pennsylvania

Joseph A. Abboud, MD Letha Y. Griffin, MD, PhD

Orthopaedic Surgeon, Associate Professor Peachtree Orthopaedic Clinic
Shoulder & Elbow Surgery Team Physician
The Rothman Institute Georgia State University
Philadelphia, Pennsylvania Atlanta, Georgia

Julie E. Adams, MD, MS Joseph A. Janicki, MD, MS

Associate Professor Assistant Professor of Orthopaedic Surgery
Orthopaedic Surgery Northwestern University Feinberg School of Medicine
Mayo Clinic Attending Physician, Orthopaedic Surgery
Rochester, Minnesota Ann & Robert H. Lurie Children’s Hospital
Chicago, Illinois
Daniel T. Altman, MD, FACS
Associate Professor of Orthopaedic Surgery Robert Z. Tashjian, MD
Drexel University College of Medicine Associate Professor
Allegheny General Hospital Orthopaedics
Pittsburgh, Pennsylvania University of Utah School of Medicine
Salt Lake City, Utah
Umur Aydogan, MD
Assistant Professor of Orthopaedics Kelly L. VanderHave, MD
Foot and Ankle Surgery Carolinas Medical Center
Bone and Joint Institute Levine Children’s Specialty Center
Penn State Milton S. Hershey Medical Center Pediatric Orthopaedics
Hershey, Pennsylvania Charlotte, North Carolina

Robert A. Gallo, MD Kathleen Weber, MD, MS

Associate Professor Assistant Professor
Orthopaedic Surgery Midwest Orthopaedics at Rush
Hershey Medical Center Rush University Medical Center
Hershey, Pennsylvania Chicago, Illinois

iv Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

 Editorial Board Disclosures
Dr. Armstrong or an immediate family member is a member
of a speakers’ bureau or has made paid presentations on
behalf of, serves as a paid consultant to or is an employee of,
and serves as an unpaid consultant to Zimmer; and serves as
a board member, owner, officer, or committee member of the
American Orthopaedic Association.
Dr. Abboud or an immediate family member serves as a
board member, owner, officer, or committee member of the
American Shoulder and Elbow Surgeons and the Mid-
Atlantic Shoulder and Elbow Society; serves as a paid
consultant to or is an employee of DePuy, A Johnson &
Johnson Company, DJ Orthopaedics, Integra, MinInvasive,
and Tornier; has received royalties from and has stock or
stock options held in MinInvasive; and has received research
or institutional support from DePuy, A Johnson & Johnson
Company, Integra, Tornier, and Zimmer.
Dr. Adams or an immediate family member has received
royalties from Arthrex; serves as a board member, owner,
officer, or committee member of the American Association
for Hand Surgery, the American Shoulder and Elbow
Surgeons, the American Society for Surgery of the Hand,
the Arthroscopy Association of North America, and the
Minnesota Orthopaedic Society; and is a member of a
speakers’ bureau or has made paid presentations on behalf of
Arthrex.
Dr. Altman or an immediate family member is a member of a
speakers’ bureau or has made paid presentations on behalf of
AO North America.
Neither Dr. Aydogan nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
© 2016 American Academy of Orthopaedic Surgeons
Dr. Gallo or an immediate family member serves as a
board member, owner, officer, or committee member of the
American Academy of Orthopaedic Surgeons, the American
Orthopaedic Association, the American Orthopaedic Society
for Sports Medicine, and the Arthroscopy Association of
North America.
Dr. Griffin or an immediate family member serves as a
board member, owner, officer, or committee member of the
American Orthopaedic Society for Sports Medicine, the
Orthopaedic Research and Education Foundation, and the
Piedmont Hospital Board of Directors.
Mr. Hubbard or an immediate family member serves as a
paid consultant to or is an employee of and serves as an
unpaid consultant to Zimmer.
Dr. Janicki or an immediate family member serves as a
board member, owner, officer, or committee member of the
Pediatric Orthopaedic Society of North America and has
stock or stock options held in Pfizer.
Dr. Tashjian or an immediate family member serves as a paid
consultant to or is an employee of Mitek and Tornier.
Neither Dr. VanderHave nor any immediate family member
has received anything of value from or has stock or stock
options held in a commercial company or institution related
directly or indirectly to the content of this publication.
Neither Dr. Weber nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Essentials of Musculoskeletal Care 5 v
 Contributors
Albert J. Aboulafia, MD, FACS, MBA Marcel Gilli, MD Joseph M. Lane, MD
Medical Director, Weinberg Anesthesiologist Professor of Orthopaedic Surgery
Cancer Institute American Anesthesiology of Georgia Department of Orthopaedics
Director, Sarcoma Services Piedmont Hospital Weill Cornell Medical College
Associate Professor of Orthopaedics Atlanta, Georgia New York, New York
and Oncology, Georgetown University
Jordyn R. Griffin, MD Laurel R. Lemasters, MD
School of Medicine
Resident Physician Musculoskeletal Radiologist
Franklin Square Hospital and
Internal Medicine, Pediatrics Northwest Radiology Consultants
Sinai Hospital
University of Kentucky Atlanta, Georgia
Baltimore, Maryland
Lexington, Kentucky
Tanya Maxwell, MS, L/ATC
Lindsay M. Andras, MD
George N. Guild III, MD Clinical Coordinator for Dr. Letha Griffin
Assistant Professor of Orthopaedics
Orthopaedic Surgeon Peachtree Orthopaedic Clinic
Children’s Orthopaedic Center
Peachtree Orthopaedic Clinic Atlanta, Georgia
Children’s Hospital Los Angeles
Northside Hospital
Keck School of Medicine of the Thomas J. Moore, MD
Atlanta, Georgia
University of Southern California Associate Professor
Los Angeles, California Stephen C. Hamilton, MD Department of Orthopaedics
Orthopaedic Surgeon Emory School of Medicine
Laura L. Bellaire, MD
Beacon Orthopaedics Atlanta, Georgia
Resident
Cincinnati, Ohio
Orthopaedic Surgery Robert A. Murphy, MS, ATC
Emory University Douglas Hollern, MD Associate Athletic Director for Sports
Atlanta, Georgia Medical Student Medicine and Nutrition
College of Medicine Athletic Department
John A. Bergfeld, MD
University of Cincinnati Georgia State University
Senior Surgeon
Cincinnati, Ohio Atlanta, Georgia
Department of Orthopaedic Surgery
Cleveland Clinic James S. Kercher, MD Michael S. Pinzur, MD
Cleveland, Ohio Orthopaedic Surgeon Professor of Orthopaedic Surgery
Peachtree Orthopaedic Clinic Department of Orthopaedic Surgery
Julie A. Dodds, MD
Atlanta, Georgia and Rehabilitation
Associate Clinical Professor
Loyola University Health System
Division of Sports Medicine Lindsey S. Knowles, DPT, STC
Maywood, Illinois
Michigan State University Owner, Physical Therapist
East Lansing, Michigan Department of Outpatient Orthopaedics David A. Schiff, MD
and Sports Physical Therapy Orthopaedic Surgeon
Gregory K. Faucher, MD
Atlanta Sport & Spine Physical Therapy Peachtree Orthopaedic Clinic
Resident Physician
Atlanta, Georgia Atlanta, Georgia
Orthopaedic Surgery
Emory University L. Andrew Koman, MD Ted Sousa, MD
Atlanta, Georgia Professor and Chair Clinical Fellow
Orthopaedic Surgery Children’s Hospital Los Angeles
Eli C. Garrard, MD
Wake Forest Baptist Health University of Southern California
Resident
Winston-Salem, North Carolina Los Angeles, California
Department of Orthopaedic Surgery
Emory University Harlan McMillan Starr, Jr, MD
Atlanta, Georgia Orthopaedic Surgeon
Georgia Hand, Shoulder, & Elbow
Atlanta, Georgia
Contributors from the American Academy of Pediatrics

Pooya Hosseinzadeh, MD Brien Rabenhorst, MD

Assistant Professor Assistant Professor of Orthopaedic Surgery
Department of Pediatric Orthopedics University of Arkansas for Medical Sciences
Baptist Children’s Hospital Little Rock, Arkansas
Miami, Florida
Brian A. Shaw, MD
Thomas G. McPartland, MD Associate Professor of Orthopaedic Surgery
Assistant Clinical Professor Orthopedic Surgery Children’s Hospital Colorado
Department of Orthopedic Surgery University of Colorado School of Medicine
Rutgers-Robert Wood Johnson Medical School Colorado Springs, Colorado
New Brunswick, New Jersey

vi Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

 Contributors’ Disclosures
Dr. Aboulafia or an immediate family member has received
royalties from and has stock or stock options held in Amgen
and serves as a board member, owner, officer, or committee
member of the Musculoskeletal Tumor Society.
Dr. Andras or an immediate family member serves as a board
member, owner, officer, or committee member of the Pediatric
Orthopaedic Society of North America and has stock or stock
options held in Eli Lilly.
Neither Dr. Bellaire nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Neither Dr. Bergfeld nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Dr. Dodds or an immediate family member serves as a
board member, owner, officer, or committee member of the
Arthroscopy Association of North America.
Neither Dr. Faucher nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Dr. Garrard or an immediate family member is an employee
of Sanofi-Aventis.
Neither Dr. Gilli nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Dr. Griffin or an immediate family member serves as a
board member, owner, officer, or committee member of the
American Orthopaedic Society for Sports Medicine and the
Orthopaedic Research and Education Foundation.
Neither Dr. Guild nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Neither Dr. Hamilton nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Neither Dr. Hollern nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Neither Dr. Hosseinzadeh nor any immediate family member
has received anything of value from or has stock or stock
options held in a commercial company or institution related
directly or indirectly to the content of this publication.
Dr. Kercher or an immediate family member serves as a
board member, owner, officer, or committee member of
the American Academy of Orthopaedic Surgeons and the
American Orthopaedic Society for Sports Medicine.
Neither Dr. Knowles nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Dr. Koman or an immediate family member has stock or
stock options held in DT Scimed, KeraNetics, Orthovatum,
and Zellko; has received nonincome support (such as
equipment or services), commercially derived honoraria, or
other non-research–related funding (such as paid travel) from
© 2016 American Academy of Orthopaedic Surgeons
KeraNetics, Orthovatum, and Zellko; and serves as a board
member, owner, officer, or committee member of the Southern
Orthopaedic Association and the American Orthopaedic
Association.
Dr. Lane or an immediate family member serves as a
board member, owner, officer, or committee member of the
American Academy of Orthopaedic Surgeons, the Association
of Bone and Joint Surgeons, the American Osteopathic
Association, the American Society for Bone and Mineral
Research, the Musculoskeletal Tumor Society, and the
Orthopaedic Research Society; serves as a paid consultant
to or is an employee of Bone Therapeutics, Inc., CollPlant,
Harvest, Inc., ISTO, BiologicsMD, and Graftys; has stock or
stock options held in Dfine and CollPlant; and has received
research or institutional support from Merck.
Neither Dr. Lemasters nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Neither Ms. Maxwell nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Dr. McPartland or an immediate family member has stock
or stock options held in Johnson & Johnson and serves as a
board member, owner, officer, or committee member of the
Pediatric Orthopaedic Society of North America.
Neither Dr. Moore nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Mr. Murphy or an immediate family member serves as a
board member, owner, officer, or committee member of the
College Athletic Trainers’ Society.
Dr. Pinzur or an immediate family member serves as a
board member, owner, officer, or committee member of the
American Academy of Orthopaedic Surgeons; is a member of
a speakers’ bureau or has made paid presentations on behalf of
Smith & Nephew, Stryker, and Wright Medical Technology;
and serves as a paid consultant to or is an employee of Wright
Medical Technology.
Neither Dr. Rabenhorst nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Neither Dr. Schiff nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Dr. Shaw or an immediate family member serves as a
board member, owner, officer, or committee member of
the American Academy of Pediatrics and the Pediatric
Orthopaedic Society of North America and has stock or stock
options held in Biomet, Johnson & Johnson, Medtronic,
Merck, Pfizer, Stryker, and Zimmer.
Neither Dr. Sousa nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Neither Dr. Starr nor any immediate family member has
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.
Essentials of Musculoskeletal Care 5 vii
 Dedication
To healthcare providers everywhere—who devote their careers to the health
and well-being of individual patients and families, both young and old.

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 ix

 Preface
Essentials of Musculoskeletal Care bridges the gap
between what primary care physicians were taught in
medical school and what they need to know to evaluate
and manage common musculoskeletal conditions. This
text is used for immediate, point-of-care guidance
in decision making and intervention. Physicians and
allied healthcare providers also often use the images in
this text to educate their patients regarding conditions
and treatments, as well as suggested at-home exercises.
Essentials also helps physicians decide which cases
to treat themselves and which to refer. Since the first
edition of Essentials of Musculoskeletal Care was
published in 1997, more than 150,000 copies have been
sold.
Essentials of Musculoskeletal Care is used by
physicians in family practice, internists, specialists in
physical medicine and rehabilitation, pediatricians,
physicians in the armed forces, physicians in
occupational medicine, physicians in sports medicine,
athletic trainers, physical therapists, emergency
medicine physicians, nurse practitioners, physician
assistants, residents in family practice and orthopaedic
surgery, orthopaedic surgeons, osteopathic physicians,
and many others. In addition, although not designed as
a textbook, Essentials has been adopted as a required
or recommended text by numerous teaching programs,
both for clinical rotations and for courses such as
Concepts in Primary Care, Orthopaedic Injuries,
Primary Care of Adults, and Musculoskeletal Clinical
Medicine. Students indicate that Essentials is the only
text that follows them from the classroom into clinical
practice.
This fifth edition of Essentials of Musculoskeletal
Care has been improved and enhanced with additional
illustrations, tables, and injection/aspiration videos.
Sections and chapters have been reviewed and
updated, and new topics have been added, including
a chapter on sports-related concussions in the
General Orthopaedics section and another chapter
on concussion in the Pediatric Orthopaedics section.
In addition, rehabilitation prescriptions with home
exercise programs and general musculoskeletal
© 2016 American Academy of Orthopaedic Surgeons
conditioning programs are available in the text and as
patient handouts that can be printed from the website
that accompanies this publication. This title is also
available as an eBook.
I am indebted to the Board of Directors of the
American Academy of Orthopaedic Surgeons
(AAOS) and to the executive staff of AAOS for their
commitment to excellence in education. My thanks
also go to the Editorial Board for this fifth edition
for their commitment to this project: section editors
Letha Yurko Griffin (General Orthopaedics); Robert
Z. Tashjian (Shoulder); Joseph A. Abboud (Elbow and
Forearm); Julie E. Adams (Hand and Wrist); Kathleen
Weber (Hip and Thigh); Robert A. Gallo (Knee and
Lower Leg); Umur Aydogan (Foot and Ankle); Daniel
T. Altman (Spine); Kelly L. VanderHave and Joseph
A. Janicki (Pediatric Orthopaedics); and Mark C.
Hubbard, who oversaw the rehabilitation content
and served as coeditor. I also would like to thank
the following AAOS staff for their work on this
publication: Hans Koelsch, Director, Publications;
Maureen Geoghegan, Director of Marketing; Monica
Baum; Lisa Claxton Moore; Laura Goetz; Genevieve
Charet; Courtney Dunker; Abram Fassler; Susan
Baim; Charlie Baldwin; Emily Nickel; Hollie Muir;
Karen Danca; Suzanne O’Reilly; Michelle Wild;
Steven Kellert; Brian Moore; Katie Hovany; Laszlo
Dianovsky; Susan Reindl; Mike Johnson; Derrick
Philips; and Abel Jimenez.
Once again, the AAOS is grateful for the support of
the American Academy of Pediatrics (AAP) and thank
them for serving as a valuable professional Academy
partner in the Essentials project. The comments from
the AAP as well as from the internists, physiatrists,
family practitioners, orthopaedic residents, medical
students, and others who use this book have helped
us continuously improve this publication, leading to
improvements in musculoskeletal education and
patient care.
April D. Armstrong, BSc(PT), MSc, MD, FRCSC
Editor
Essentials of Musculoskeletal Care 5 xi
 How to Use
Essentials of Musculoskeletal Care 5th Edition
Essentials of Musculoskeletal Care provides concise content in a practical and easy-to-use format. To access
the associated videos (physical examinations, maneuvers, injections, aspirations) and printable PDFs of home
exercise programs, click the video icons and links throughout the text.

Pain diagram opens each section.

Shows areas of pain and identifies
conditions typically associated with
each pain location. Names chapter in
which condition is discussed.

Table of contents lists conditions in

alphabetic order.

Anatomic art at beginning of section

for handy reference.

Physical examination shows

photographs and step-by-step
descriptions of physical examination
maneuvers: inspection and palpation,
range of motion, muscle testing, and
special tests. Symbol indicates that
video demonstrations are available by
clicking the video icon.

xii
Conditions chapters include:
a. Synonyms
b. Clinical symptoms
c. Physical examination pearls
d. Diagnostic tests
e. Differential diagnosis
f. Adverse outcomes of the disease
g. Treatment
h. Rehabilitation prescription
i. Adverse outcomes of treatment
j. Referral decisions/Red flags

Home exercise program includes:

a. Symbol indicating customizable, printable
PDF of the home exercise program is
available by clicking the PDF icon (AAOS
access app) or the resources arrow at
digital.aaos.org (see image)
b. Concise table of exercises
c. Step-by-step instructions and illustrations

Procedures include:
a. Symbol indicating video is
available by clicking the
link.
b. List of materials
c. Step-by-step instructions

xiii

General Orthopaedics
xx Pain Diagram
2 Anatomy
3 Overview of General
Orthopaedics
8 Principles of
Musculoskeletal Evaluation
15 Amputations of the Lower
Extremity
24 Anesthesia for Orthopaedic
Surgery
32 Arthritis: Osteoarthritis
39 Complementary and
Alternative Medicine
Therapies for Osteoarthritis
46 Arthritis: Rheumatoid
Arthritis
53 Arthritis: Seronegative
Spondyloarthropathies
58 Compartment Syndrome
65 Complex Regional Pain
Syndrome
72 Concussion: Sports-Related
76 Crystal Deposition Diseases
82 Deep Vein Thrombosis
xiv Essentials of Musculoskeletal Care 5
Table of Contents
SECTION ONE
90 Diffuse Idiopathic Skeletal
Hyperostosis
92 Drugs: Corticosteroid
Injections
96 Drugs: Nonsteroidal
Anti-Inflammatory Drugs
100 Falls and Traumatic Injuries
in the Elderly Patient
109 Fibromyalgia Syndrome
115 Fracture Evaluation and
Management Principles
122 Fracture Healing
127 Fracture Splinting
Principles
135 Imaging: Principles and
Techniques
144 Infection: Osteomyelitis
147 Infection: Septic Arthritis
152 Lyme Disease
156 Osteoporosis
166 Overuse Syndromes
173 Pain Management in the
Orthopaedic Patient
177 Pain: Nonorganic
Symptoms and Signs
© 2016 American Academy of Orthopaedic Surgeons
181 Preoperative Evaluation of
Medical Comorbidities
188 Rehabilitation and
Therapeutic Modalities
198 Musculoskeletal
Conditioning: Helping
Patients Prevent Injury and
Stay Fit
201 Home Exercise Program for
Shoulder Conditioning
209 Home Exercise Program for
Hip Conditioning
219 Home Exercise Program for
Knee Conditioning
226 Home Exercise Program
for Foot and Ankle
Conditioning
233 Home Exercise Program for
Lumbar Spine Conditioning
238 Rehabilitation: Canes,
Crutches, and Walkers
244 Sports Medicine Evaluation
and Management Principles
249 Sprains and Strains
253 Tumors of Bone

258 Pain Diagram
260 Anatomy
261 Overview of the Shoulder
265 Home Exercise Program for
Shoulder Conditioning
271 Physical Examination
of the Shoulder
282 Acromioclavicular Injuries
286 Home Exercise Program for
Acromioclavicular Injuries
289 Procedure:
Acromioclavicular
Joint Injection
291 Arthritis of the Shoulder
294 Burners and Other Brachial
Plexus Injuries
Elbow and Forearm
364 Pain Diagram
366 Anatomy
367 Overview of the Elbow
and Forearm
370 Physical Examination
of the Elbow and Forearm
377 Arthritis of the Elbow
381 Procedure: Elbow Joint
Injection and Aspiration—
Lateral Approach
383 Dislocation of the Elbow
© 2016 American Academy of Orthopaedic Surgeons
SECTION TWO
Shoulder
298 Fracture of the Clavicle
301 Fracture of the Humeral
Shaft
304 Fracture of the Proximal
Humerus
308 Fracture of the Scapula
311 Frozen Shoulder
314 Home Exercise Program for
Frozen Shoulder
316 Procedure: Shoulder Joint
Injection and Aspiration:
Posterior
318 Impingement Syndrome
322 Home Exercise Program for
Shoulder Impingement
325 Procedure: Subacromial
Bursa Injection
327 Overhead Throwing
Shoulder Injuries
SECTION THREE
386 Fracture of the Distal
Humerus
389 Fracture of the Olecranon
392 Fracture of the Radial Head
395 Lateral and Medial
Epicondylitis
399 Home Exercise Program for
Epicondylitis
402 Procedure: Tennis Elbow
Injection
404 Olecranon Bursitis
Essentials of Musculoskeletal Care 5
334 Rotator Cuff Tear
338 Home Exercise Program for
Rotator Cuff Tear
341 Rupture of the Proximal
Biceps Tendon
344 Shoulder Instability
350 Procedure: Reduction
of Anterior Shoulder
Dislocation
353 Superior Labrum Anterior
to Posterior Lesions
356 Home Exercise Program for
SLAP Lesions
358 Thoracic Outlet Syndrome
361 Home Exercise Program for
Thoracic Outlet Syndrome
407 Procedure: Olecranon Bursa
Aspiration
409 Nerve Compression
Syndromes
413 Home Exercise Program for
Radial Tunnel Syndrome
416 Rupture of the Distal Biceps
Tendon
418 Ulnar Collateral Ligament
Tear
xv

Hand and Wrist
422 Pain Diagram
424 Anatomy
425 Overview of the Hand
and Wrist
430 Physical Examination
of the Hand and Wrist
442 Animal Bites
445 Arthritis of the Hand
448 Procedure:
Metacarpophalangeal or
Proximal Interphalangeal
Joint Injection
450 Arthritis of the Thumb
Carpometacarpal Joint
453 Procedure: Thumb
Carpometacarpal Joint
Injection
455 Arthritis of the Wrist
457 Procedure: Wrist
Aspiration/Injection
459 Boutonnière Deformity
462 Carpal Tunnel Syndrome
550 Pain Diagram
552 Anatomy
553 Overview of the Hip
and Thigh
558 Home Exercise Program
for Hip Conditioning
566 Physical Examination of
the Hip and Thigh
574 Dislocation of the Hip
(Acute, Traumatic)
578 Fracture of the Femoral
Shaft
581 Fracture of the Pelvis
xvi Essentials of Musculoskeletal Care 5
SECTION FOUR
466 Home Program for Carpal
Tunnel Syndrome
468 Procedure: Carpal Tunnel
Injection
470 de Quervain Tenosynovitis
472 Procedure: de Quervain
Tenosynovitis Injection
474 Dupuytren Contracture
477 Fingertip Infections
481 Procedure: Digital
Anesthetic Block (Hand)
483 Fingertip Injuries/
Amputations
486 Flexor Tendon Injuries
490 Flexor Tendon Sheath
Infections
493 Fracture of the Base of the
Thumb Metacarpal
495 Fracture of the Hook
of the Hamate
498 Fracture of the Distal
Radius
SECTION FIVE
Hip and Thigh
585 Fracture of the Proximal
Femur
589 Hip Impingement
593 Inflammatory Arthritis
596 Lateral Femoral Cutaneous
Nerve Syndrome
599 Osteoarthritis of the Hip
602 Osteonecrosis of the Hip
605 Snapping Hip
608 Home Exercise Program
for Snapping Hip
612 Strains of the Hip
615 Home Exercise Program
for Strains of the Hip
© 2016 American Academy of Orthopaedic Surgeons
502 Fracture of the Metacarpals
and Phalanges
507 Fracture of the Scaphoid
510 Ganglion of the Wrist
and Hand
515 Procedure: Dorsal Wrist
Ganglion Aspiration
517 Human Bite Wounds
520 Kienböck Disease
522 Mallet Finger
525 Nail Bed Injuries
528 Procedure: Fishhook
Removal
531 Sprains and Dislocations
of the Hand
537 Trigger Finger
540 Procedure: Trigger Finger
Injection
542 Tumors of the Hand
and Wrist
546 Ulnar Nerve Entrapment
at the Wrist
619 Strains of the Thigh
622 Home Exercise Program
for Strains of the Thigh
627 Stress Fracture of the
Femoral Neck
630 Transient Osteoporosis
of the Hip
632 Trochanteric Bursitis
635 Home Exercise Program
for Trochanteric Bursitis
638 Procedure: Trochanteric
Bursitis Injection

Knee and Lower Leg
640 Pain Diagram
642 Anatomy
643 Overview of the Knee
and Lower Leg
651 Home Exercise Program for
Knee Conditioning
657 Physical Examination of the
Knee and Lower Leg
668 Anterior Cruciate
Ligament Tear
672 Home Exercise Program for
ACL Tear
675 Procedure: Knee Joint
Aspiration/Injection
678 Arthritis of the Knee
683 Home Exercise Program
for Arthritis
686 Bursitis of the Knee
690 Procedure: Pes Anserine
Bursa Injection
© 2016 American Academy of Orthopaedic Surgeons
SECTION SIX
692 Claudication
694 Collateral Ligament Tear
698 Home Exercise Program for
Collateral Ligament Tear
701 Compartment Syndrome
705 Contusions
707 Fractures About the Knee
711 Iliotibial Band Syndrome
713 Gastrocnemius Tear
715 Home Exercise Program for
Medial Gastrocnemius Tear
717 Meniscal Tear
722 Home Exercise Program for
Meniscal Tear
724 Osteonecrosis of the
Femoral Condyle
727 Patellar/Quadriceps
Tendinitis
Essentials of Musculoskeletal Care 5
730 Home Exercise Program
for Patellar/Quadriceps
Tendinitis
732 Patellar/Quadriceps Tendon
Ruptures
735 Patellofemoral Maltracking
739 Patellofemoral Pain
743 Home Exercise Program for
Patellofemoral Pain
746 Plica Syndrome
749 Home Exercise Program for
Plica Syndrome
751 Popliteal Cyst
754 Posterior Cruciate
Ligament Tear
758 Home Exercise Program
for PCL Injury
760 Shin Splints
762 Stress Fracture
xvii

Foot and Ankle
766 Pain Diagram
768 Anatomy
769 Overview of the Foot
and Ankle
773 Home Exercise Program
for Foot and Ankle
Conditioning
779 Physical Examination of the
Foot and Ankle
794 Achilles Tendon Tear
797 Home Exercise Program for
Minor Achilles Tendon Tear
800 Ankle Sprain
804 Home Exercise Program
for Ankle Sprain (Initial
Program)
808 Arthritis of the Foot
and Ankle
812 Procedure: Ankle Joint
Injection
814 Bunionette
816 Procedure: Application of a
Metatarsal Pad
817 Chronic Lateral Ankle Pain
821 Corns and Calluses
824 Procedure: Trimming a
Corn or Callus
922 Pain Diagram
924 Anatomy
925 Overview of the Spine
934 Home Exercise Program
for Lumbar Spine
Conditioning
939 Physical Examination of
the Spine
956 Cauda Equina Syndrome
958 Cervical Radiculopathy
961 Cervical Spondylosis
xviii Essentials of Musculoskeletal Care 5
SECTION SEVEN
825 Dance Injuries to the Foot
and Ankle
830 The Diabetic Foot
834 Procedure: Care of Diabetic
Feet
837 Fracture-Dislocations
of the Midfoot
840 Fractures of the Ankle
843 Fractures of the Calcaneus
and Talus
846 Fracture of the Metatarsals
849 Fracture of the Phalanges
851 Fracture of the Sesamoid
854 Procedure: Digital
Anesthetic Block (Foot)
855 Hallux Rigidus
858 Hallux Valgus
861 Ingrown Toenail
863 Procedure: Nail Plate
Avulsion
865 Interdigital (Morton)
Neuroma
868 Procedure: Interdigital
(Morton) Neuroma Injection
870 Metatarsalgia
SECTION EIGHT
Spine
965 Cervical Strain
968 Home Exercise Program
for Cervical Strain
970 Fractures of the Cervical
Spine
973 Fractures of the Thoracic
or Lumbar Spine
976 Low Back Pain: Acute
980 Home Exercise Program
for Acute Low Back Pain
982 Low Back Pain: Chronic
© 2016 American Academy of Orthopaedic Surgeons
872 Nail Fungus Infection
874 Orthotic Devices
877 Plantar Fasciitis
881 Home Exercise Program for
Plantar Fasciitis
883 Procedure: Plantar Fasciitis
Injection
885 Plantar Warts
887 Posterior Heel Pain
890 Home Exercise Program for
Posterior Heel Pain
892 Posterior Tibial Tendon
Dysfunction
896 Rheumatoid Arthritis of the
Foot and Ankle
899 Sesamoiditis
901 Shoe Wear
905 Soft-Tissue Masses of the
Foot and Ankle
907 Stress Fractures of the
Foot and Ankle
910 Tarsal Tunnel Syndrome
913 Toe Deformities
916 Home Exercise Program for
Toe Strengthening
919 Turf Toe
985 Home Exercise Program
for Low Back Stability and
Strength: Introductory
987 Lumbar Herniated Disk
992 Lumbar Spinal Stenosis
996 Metastatic Disease
999 Scoliosis in Adults
1002 Spinal Orthoses
1006 Spondylolisthesis:
Degenerative
1008 Spondylolisthesis: Isthmic

Pediatric Orthopaedics
1011 Overview of Pediatric
Orthopaedics
1013 Pediatric Physical
Examination
1025 Anterior Knee Pain
1028 Back Pain
1032 Elbow Pain
1037 Foot and Ankle Pain
1041 Growing Pain
1043 Accessory Navicular
1045 Calcaneal Apophysitis
1047 Cavus Foot Deformity
1051 Child Abuse
1055 Clubfoot
1059 Complex Regional Pain
Syndrome
1062 Concussion
1066 Congenital Deficiencies of
the Lower Extremity
1071 Congenital Deficiencies of
the Upper Extremity
1074 Congenital Deformities of
the Lower Extremity
1080 Congenital Deformities of
the Upper Extremity
1084 Developmental Dysplasia
of the Hip
1222 Glossary
1239 Index
© 2016 American Academy of Orthopaedic Surgeons
SECTION NINE
1090 Discitis
1093 Evaluation of the
Limping Child
1098 Procedure: Hip Aspiration
1100 Flatfoot
1104 Fractures in Children
1106 Fractures of the Growth
Plate
1109 Fractures About the Elbow
1114 Fractures of the Clavicle
and Proximal Humerus
1117 Fractures of the Distal
Forearm
1120 Fractures of the Proximal
and Middle Forearm
1122 Fractures of the Femur
1125 Fractures of the Tibia
1128 Genu Valgum
1132 Genu Varum
1135 Intoeing and Outtoeing
1141 Juvenile Idiopathic
Arthritis
1146 Kyphosis
1150 Legg-Calvé-Perthes
Disease
1155 Little Leaguer’s Elbow
Essentials of Musculoskeletal Care 5
1159 Metatarsus Adductus
1163 Neonatal Brachial Plexus
Palsy
1166 Osgood-Schlatter Disease
1168 Osteochondral Lesions of
the Talus
1170 Osteochondritis Dissecans
1173 Osteomyelitis
1177 Pediatric Sports
Participation
1180 Preparticipation Physical
Evaluation
1188 Scoliosis
1193 Septic Arthritis
1197 Seronegative
Spondyloarthropathies
1199 Shoes for Children
1201 Slipped Capital Femoral
Epiphysis
1205 Spondylolysis/
Spondylolisthesis
1209 Tarsal Coalition
1212 Toe Walking
1215 Torticollis
1220 Transient Synovitis
of the Hip
xix
 PAIN DIAGRAM
General Orthopaedics

Osteoporosis

Osteoarthritis

Rheumatoid arthritis

Diffuse idiopathic
skeletal hyperostosis
(DISH)

Seronegative
spondyloarthropathies

Rheumatoid arthritis

Complex regional pain

syndrome (CRPS)

Osteoarthritis

Rheumatoid arthritis

Deep vein thrombosis

Complex regional pain

syndrome (CRPS)

Osteoarthritis

Rheumatoid arthritis Rheumatoid arthritis

Crystal deposition disease
Crystal deposition
disease

xx Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

 SECTION 1

General Orthopaedics
xx Pain Diagram 65 Complex Regional Pain 127 Fracture Splinting 201 Home Exercise
Syndrome Principles Program for Shoulder
2 Anatomy
72 Concussion: 135 Imaging: Principles and Conditioning
3 Overview of General
Sports-Related Techniques 209 Home Exercise Program
Orthopaedics
76 Crystal Deposition 144 Infection: Osteomyelitis for Hip Conditioning
8 Principles of
Diseases 147 Infection: Septic Arthritis 219 Home Exercise Program
Musculoskeletal
82 Deep Vein Thrombosis for Knee Conditioning
Evaluation 152 Lyme Disease
90 Diffuse Idiopathic 226 Home Exercise Program
15 Amputations of the 156 Osteoporosis
Skeletal Hyperostosis for Foot and Ankle
Lower Extremity
166 Overuse Syndromes Conditioning
24 Anesthesia for 92 Drugs: Corticosteroid
Orthopaedic Surgery Injections 173 Pain Management in the 233 Home Exercise Program
Orthopaedic Patient for Lumbar Spine
32 Arthritis: Osteoarthritis 96 Drugs: Nonsteroidal Conditioning
Anti-Inflammatory Drugs 177 Pain: Nonorganic
39 Complementary Symptoms and Signs 238 Rehabilitation: Canes,
and Alternative 100 Falls and Traumatic Crutches, and Walkers
Medicine Therapies for Injuries in the Elderly 181 Preoperative Evaluation
Osteoarthritis Patient of Medical Comorbidities 244 Sports Medicine
Evaluation and
46 Arthritis: Rheumatoid 109 Fibromyalgia Syndrome 188 Rehabilitation and Management Principles
Arthritis Therapeutic Modalities
115 Fracture Evaluation and 249 Sprains and Strains
53 Arthritis: Seronegative Management Principles 198 Musculoskeletal
Conditioning: Helping 253 Tumors of Bone
Spondyloarthropathies 122 Fracture Healing
Patients Prevent Injury
58 Compartment Syndrome
and Stay Fit

Section Editor
Letha Y. Griffin, MD, PhD
Peachtree Orthopaedic Clinic
Team Physician
Georgia State University
Atlanta, Georgia

Albert J. Aboulafia, MD, FACS, MBA
Medical Director, Weinberg
Cancer Institute
Director, Sarcoma Services
Associate Professor of
Orthopaedics and Oncology,
Georgetown University School of
Medicine
Franklin Square Hospital and Sinai
Hospital
Baltimore, Maryland
Lindsay M. Andras, MD
Assistant Professor of Orthopaedics
Department of Orthopaedic Surgery
Children’s Orthopaedic Center
Children’s Hospital Los Angeles
Keck School of Medicine of the
University of Southern California
Los Angeles, California
American Anesthesiology of Georgia
Laura L. Bellaire, MD
Resident
Orthopaedic Surgery
Emory University
Atlanta, Georgia
Internal Medicine, Pediatrics
John A. Bergfeld, MD
Senior Surgeon
Department of Orthopaedic Surgery
Cleveland Clinic
Cleveland, Ohio
© 2016 American Academy of Orthopaedic Surgeons
Julie A. Dodds, MD
Associate Clinical Professor
Division of Sports Medicine
Michigan State University
East Lansing, Michigan
Gregory K. Faucher, MD
Resident Physician
Orthopaedic Surgery
Emory University
Atlanta, Georgia
Eli C. Garrard, MD
Resident
Emory University
Atlanta, Georgia
Marcel Gilli, MD
Anesthesiologist
Piedmont Hospital
Atlanta, Georgia
Jordyn R. Griffin, MD
Resident Physician
University of Kentucky
Lexington, Kentucky
Contributors
George N. Guild III, MD
Orthopaedic Surgeon
Peachtree Orthopaedic Clinic
Northside Hospital
Atlanta, Georgia
Stephen C. Hamilton, MD
Orthopaedic Surgeon
Beacon Orthopaedics
Cincinnati, Ohio
Douglas Hollern, MD
Medical Student
College of Medicine
University of Cincinnati
Cincinnati, Ohio
Mark C. Hubbard, MPT
Physical Therapist
Bone and Joint Institute
Penn State Milton S. Hershey
Medical Center
Hershey, Pennsylvania
James S. Kercher, MD
Orthopaedic Surgeon
Peachtree Orthopaedic Clinic
Atlanta, Georgia
Lindsey S. Knowles, DPT, STC
Owner, Physical Therapist
Department of Outpatient
Orthopaedics and Sports
Physical Therapy
Atlanta Sport & Spine Physical Therapy
Atlanta, Georgia
L. Andrew Koman, MD
Professor and Chair
Orthopaedic Surgery
Wake Forest Baptist Health
Winston-Salem, North Carolina
Joseph M. Lane, MD
Professor of Orthopaedic Surgery
Department of Orthopaedics
Weill Cornell Medical College
New York, New York
Laurel R. Lemasters, MD
Musculoskeletal Radiologist
Northwest Radiology Consultants
Atlanta, Georgia
Tanya Maxwell, MS, L/ATC
Clinical Coordinator for Dr. Letha Griffin
Peachtree Orthopaedic Clinic
Atlanta, Georgia
Essentials of Musculoskeletal Care 5
Thomas J. Moore, MD
Associate Professor
Department of Orthopaedics
Emory School of Medicine
Atlanta, Georgia
Robert A. Murphy, MS, ATC
Associate Athletic Director for Sports
Medicine and Nutrition
Athletic Department
Georgia State University
Atlanta, Georgia
Michael S. Pinzur, MD
Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
and Rehabilitation
Loyola University Health System
Maywood, Illinois
David A. Schiff, MD
Orthopaedic Surgeon
Peachtree Orthopaedic Clinic
Atlanta, Georgia
Ted Sousa, MD
Clinical Fellow
Children’s Hospital Los Angeles
University of Southern California
Los Angeles, California
Harlan McMillan Starr, Jr, MD
Orthopaedic Surgeon
Georgia Hand, Shoulder, & Elbow
Atlanta, Georgia
1
 ANATOMY—MAJOR BONES OF THE BODY

Skull

Clavicle Mandible

Scapula

Humerus

Spinal column

Radius
Pelvis
Ulna

Carpal bones
Metacarpals

Phalanges

Femur

Patella

Fibula Tibia

Metatarsals
Tarsal bones
Phalanges

2 Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

Overview of General
Orthopaedics

SECTION 1 GENERAL ORTHOPAEDICS

Bone, cartilage, muscle, tendon, ligament, and their supporting nerve
and vascular supplies are the specialized structures that make up the
musculoskeletal system. In combination, these structures provide
remarkable strength, movement, durability, and efficiency. Disease
or injury to any of these tissues may adversely affect function and
the ability to perform daily activities. This General Orthopaedics
section of Essentials of Musculoskeletal Care describes conditions
that affect multiple joints, bones, or regions; conditions that have
systemic effects; and therapeutic modalities commonly used in the
nonsurgical treatment of musculoskeletal conditions. An anatomic
drawing showing the major bones of the human body is on page 2;
a detailed anatomic drawing showing the bones and muscles of the
various anatomic areas appears at the beginning of each anatomic
section. A glossary of commonly used orthopaedic terms is provided
immediately after section 9.

Arthritis
The etiologies of arthritis range from degenerative processes
associated with aging (osteoarthritis) to acute infectious processes
(septic arthritis). Likewise, disability from arthritis ranges from
stiffness to severe pain and crippling dysfunction. Two of the most
common forms of adult arthritis encountered in clinical practice are
osteoarthritis and rheumatoid arthritis (Figure 1). Distinguishing
characteristics are listed in Table 1.
Other types of inflammatory arthritis include the seronegative
spondyloarthropathies, crystal deposition diseases, and septic
arthritis. Of these conditions, septic arthritis is the most urgent
because immediate diagnosis and efficacious treatment are required
to prevent joint destruction. Diagnosis typically involves joint
fluid analysis, in which a leukocyte count greater than 50,000 or
a differential count of 90% polymorphonucleocytes is concerning
for bacterial arthritis. Joint aspiration and culture, followed by
appropriately tailored antibiotics, and in most cases, surgical drainage
and lavage, are imperative. The crystal arthropathies present as
acute monoarticular arthritis with an abrupt onset of intense pain
and swelling. The seronegative spondyloarthropathies are a group
of disorders characterized by oligoarticular peripheral joint arthritis,
enthesitis, inflammatory changes in axial skeletal joints (sacroiliitis
and spondylitis), extra-articular sites of inflammation, association
with HLA-B27, and negative rheumatoid factor.

Bursitis and Tenosynovitis

Sterile inflammation of bursae (bursitis) and tendon sheaths
(tendinitis) occurs frequently in adults, particularly following
an injury or repetitive motion. Characteristic symptoms include

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 3

 Overview of General Orthopaedics
SECTION 1 GENERAL ORTHOPAEDICS

Figure 1 Illustration shows joints commonly affected by arthritis. Blue asterisks indicate joints predominantly
affected by osteoarthritis; red asterisks indicate joints predominantly affected by rheumatoid arthritis.
DIP = distal interphalangeal, MCP = metacarpophalangeal, MTP = metatarsophalangeal, PIP = proximal
interphalangeal.

localized pain that is exacerbated by specific movements and is

frequently relieved with rest. Classic locations of bursitis include
the olecranon, greater trochanter, and prepatellar bursa, whereas
tenosynovitis frequently affects tendon sheaths of the wrist and hand
flexor tendons and tendons about the ankle (peroneal, posterior tibial,
and Achilles). Common treatments for bursitis and tenosynovitis
include activity modification, NSAIDs, splinting, and the judicious
use of corticosteroid injections. Infectious tenosynovitis or infectious
bursitis can follow minor trauma, especially if the skin is violated.

4 Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

 Overview of General Orthopaedics

Table 1
Characteristics of Osteoarthritis Versus Rheumatoid Arthritis

SECTION 1 GENERAL ORTHOPAEDICS

Characteristic Osteoarthritis Rheumatoid Arthritis
Pathophysiology Noninflammatory, asymmetric, Autoimmune, inflammatory cytokines
articular cartilage deterioration target synovial membranes
“Wear and tear”
Demographics Most common arthritis Affects 1% of population
Incidence increases with age 3:1 female-to-male
Obesity Peak onset in the fourth and fifth
History of joint trauma or other joint decades
disease (secondary to OA)
Clinical Increased pain with use, fast-resolving Morning stiffness
stiffness Classically affects MCP, PIP, wrists,
Classically affects knees, hips, spine, MTP joints
DIP joints, thumb CMC joint Symmetric and deforming joint erosion
Crepitus, decreased joint ROM Synovial thickening and joint
tenderness to palpation
Workup Radiographs: asymmetric joint space Laboratory tests: RF (high sensitivity),
narrowing, subchondral sclerosis, anti-CCP (high specificity)
osteophytes Radiographs: bony erosions,
symmetric joint space narrowing
Treatment Exercise and weight loss, NSAIDs, NSAIDs, DMARDs, TNF-α
corticosteroid injections, antagonists, glucocorticoids
glucosamine and chondroitin Goal of treatment is to prevent
sulfate, hyaluronic acid, total irreversible joint erosion and
joint arthroplasty deformity
CCP = cyclic citrullinated peptide, CMC = carpometacarpal, DIP = distal interphalangeal, DMARDs = disease-
modifying antirheumatic drugs, MCP = metacarpophalangeal, MTP = metatarsophalangeal, OA = osteoarthritis,
PIP = proximal interphalangeal, RF = rheumatoid factor, ROM = range of motion, TNF-α = tumor necrosis factor-α.

The cardinal signs of Kanavel (Table 2) signal infection in pyogenic Table 2

flexor tenosynovitis of the finger; this condition should be addressed
urgently with surgery to prevent permanent finger dysfunction. All Cardinal Signs of Kanavel
infectious bursitis or tenosynovitis requires prompt recognition with for Hand Flexor Tendon
culture (if feasible) of the area and initial treatment with broad- Sheath Infection
spectrum antibiotics until culture results are known. Prompt referral Fusiform swelling of digit
for consideration of surgical drainage is essential.
Tenderness along tendon
sheath
Osteoporosis Digit held in flexed position
Osteoporosis is a common skeletal disorder with significant health Severe pain with passive digit
cost. Associated fragility (low-energy) fractures seen primarily in extension
the hip, distal radius, proximal humerus, and vertebrae are estimated
to total 9 million per year worldwide and are a significant source of
morbidity and mortality in an increasingly aging population. Patients
who sustain fragility fracture should be evaluated for osteoporosis
and treated when appropriate to reduce the risk for future fracture.
Dual-energy x-ray absorptiometry (DEXA) is used to screen for

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 5

 Overview of General Orthopaedics

Table 3
Major Risk Factors for Osteoporotic Fractures
SECTION 1 GENERAL ORTHOPAEDICS

Not Modifiable
Advanced age
Female sex
History of fracture as an adult
History of fracture in first-degree relative
Dementia
Poor health/frailty
Caucasian or Asian race
Possibly Modifiable
Low bone mineral density
Oral glucocorticoid use
Recurrent falls
Current tobacco use
Alcoholism
Estrogen deficiency, including menopause onset before age 45 years
Lifelong low calcium intake
Vitamin D deficiency
Low body weight
Little or no physical activity

osteoporosis, defined as a bone density 2.5 SDs below the healthy

young adult mean. Treatment of osteoporosis includes modifying
risk factors (Table 3), vitamin D and calcium supplementation, and
pharmacologic therapy. All physicians should encourage patients to
include calcium-rich foods in their diet, obtain appropriate “sunshine”
vitamin D, and exercise regularly to avoid the development of
osteoporosis. The high prevalence of vitamin D deficiency in the
United States justifies the regular screening of adolescents, adults,
and elderly patients for deficiency as part of the health maintenance
examination.

Trauma
Trauma to the musculoskeletal system may involve bones, ligaments,
or tendons. Initial management should include a thorough history;
physical examination, including assessment of neurovascular status;
imaging; and appropriate immobilization via splinting or bracing.
The skin should be inspected for wounds that extend into fractures
or joints. Open injuries necessitate urgent irrigation and débridement
to minimize the chance of infection. Injured patients should be
monitored for traumatic compartment syndrome, especially in leg
and forearm fractures; immediate surgical fasciotomy is required to
prevent catastrophic sequelae. Following trauma, immobilization of
the injured body part provides pain relief, limits further bone and

6 Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

 Overview of General Orthopaedics

soft-tissue damage, and may aid in the definitive treatment. Injury Table 4
type and severity, along with patient-specific considerations, factor
into the decision of nonsurgical versus surgical management in Signs of Elder Abuse
musculoskeletal trauma.

SECTION 1 GENERAL ORTHOPAEDICS

Signs of Physical Abuse
Abrasions
Musculoskeletal Oncology Bruises
Primary bone malignancy is uncommon. Evaluation involves clinical, Fractures
laboratory, radiographic, and pathologic correlation. Metastatic bone Signs of Emotional Abuse
disease in adults is substantially more prevalent than primary bone
Overbearing caregiver
cancer. Malignancies frequently associated with bone metastasis
include breast, prostate, lung, kidney, and thyroid tumors. New-onset depression
Dementia-like behavior
Signs of Sexual Abuse
Abuse Signs of minor trauma to
Abuse involving children, spouses, or the elderly is a complex social
anogenital area
and medical problem. Recognizing abuse can prevent catastrophic
consequences; therefore, it is essential that the appropriate social Sexually transmitted disease
service agencies be notified when a patient’s injuries are recognized (STD)
as potentially resulting from abuse. Child abuse is discussed in Signs of Neglect
the Pediatric Orthopaedics section. Spouse or elder abuse may be Malnutrition
identified by recognizing the signs listed in Table 4. The complexity Failure to take medications
of these problems and the seriousness of the consequences demand Poor grooming
familiarity with them and with available community resources. Bedsores
Signs of Financial
Exploitation
Abrupt changes in finances
Failure to pay bills
Suspicious changes in legal
documents

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 7


SECTION 1 GENERAL ORTHOPAEDICS
Table 1
History Questions Pertinent to Musculoskeletal Conditions
Pain
Nature: sharp, dull, achy,
radiating, associated with
fatigue or weakness?
Timing: increasing, decreasing,
intermittent, related to time
of day, related to activity,
related to injury?
8 Essentials of Musculoskeletal Care 5
Principles of
Musculoskeletal
Evaluation
Patients presenting with musculoskeletal problems may report pain,
stiffness, deformity, or weakness. General principles for evaluating
these patients are described here.
History
The history of the presenting condition should include onset, location,
duration, aggravators/relievers, character, and temporal factors
tailored to the specific symptom or symptoms (Table 1). Additional
questions about the patient’s medical history, social history, and
family history, and a review of systems may reveal clues that suggest
the correct diagnosis. For example, substantial weight loss in a
person who smokes may suggest that low back pain is secondary
to metastatic disease, whereas back pain in a postmenopausal
woman with a history of a fragility fracture may suggest a vertebral
compression fracture. In persons with musculoskeletal disorders, it
is important to understand the patient’s level of function before the
injury or illness.
Physical Examination
The general principles of examining the musculoskeletal system,
including inspection, palpation, range of motion, muscle testing,
motor and sensory evaluation, and special tests, are described later
in this section. The specific techniques are detailed in subsequent
anatomic sections. When examining the extremities, comparison with
Joints Back
Decreased range of motion? Radiation to buttocks or legs?
Swelling? Midline versus paravertebral?
Warmth/erythema? Sharp or aching?
Morning or activity-related pain/ Postural or height change?
stiffness? Paresthesias?
Catching or giving way? Night pain?
Instability? Bowel or bladder incontinence?
Loss of function?
Unilateral or bilateral?
Crepitus?
Related to deformity?
© 2016 American Academy of Orthopaedic Surgeons
 Principles of Musculoskeletal Evaluation

the opposite, asymptomatic extremity often is helpful in defining the

specific abnormalities in the symptomatic extremity.
Inspection/Palpation

SECTION 1 GENERAL ORTHOPAEDICS

Inspect the patient’s standing posture. Compare the affected
extremity with the opposite extremity for any difference in symmetry
or length. Note if the patient has any abnormal spine curvature or
axial asymmetry. Watch the patient walk. Analyze the stance and
swing phases of gait. Look for an antalgic gait, which is characterized
by limited stance phase on the affected extremity. Watch for
weakness of the swing-phase muscles—for example, weakness of the
ankle dorsiflexors (peroneal nerve dysfunction)—which is manifested
Figure 1 Photograph shows
by a footdrop gait.
a patient pointing to the one
Ask the patient to place one finger on the one spot that hurts the
spot that hurts the most, that is,
most to localize the problem and narrow the differential diagnosis localizing the point of maximal
(Figure 1). After exposing the area, look for swelling, erythema, tenderness.
ecchymosis, and muscular atrophy.
Palpate the affected area for tenderness, abnormal masses,
fluctuance, crepitus, or temperature changes.
Range of Motion
Measure the motion of the joints in the affected extremity or spine
and compare with normal range of motion measurements on the
unaffected side. Restricted joint motion may herald trauma, infection,
arthritis, or another inflammatory process. Measure both passive
and active range of motion. A discrepancy between active and
passive range of motion may indicate joint injury or may represent an
underlying muscle weakness.
Basic Principles
Joint range of motion is an objective measurement. The parameters
for rating musculoskeletal disability, whether for government or other
agencies, are based on the degree to which joint motion is impaired.
Joint motion can be estimated visually, but a goniometer enhances
accuracy and is preferred for evaluating motion of the elbow, wrist,
digits, knee, ankle, and great toe. A goniometer is less useful in
measuring hip and shoulder motion because the overlying soft tissues
do not allow the same degree of precision.
Zero Starting Position
Describing joint motion with reference to the accepted Zero
Starting Position for each joint is necessary to provide consistent
communication between observers. The Zero Starting Position for
each joint is described in the examination chapter of each section and
in Figures 2 and 3. For most joints, the Zero Starting Position is the
anatomic position of the extremity in extension.
To measure joint motion, start by placing the joint in the Zero
Starting Position. Place the center of the goniometer at the center
of the joint. Align one arm of the goniometer with the bony axis of
the proximal segment and the other end of the goniometer with the
bony axis of the distal segment (Figure 4). Hold the upper end of
the goniometer in place while the joint is moved through its arc of

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 9

 Principles of Musculoskeletal Evaluation
SECTION 1 GENERAL ORTHOPAEDICS

Figure 2 Illustrations show means of measuring joint motion in the upper extremity. (Reproduced from Greene
WB, Heckman JD, eds: The Clinical Measurement of Joint Motion. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 1994.)

motion. When the joint is at the farthest extent of the arc of motion,
realign the distal arm of the goniometer with the axis of the distal
segment and read the degree of joint motion from the goniometer.
Definitions of Limited Motion
The terminology for describing limited motion is illustrated in
Figure 5. The knee joint depicted in this photograph can be neither

10 Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

 Principles of Musculoskeletal Evaluation

SECTION 1 GENERAL ORTHOPAEDICS

Figure 3 Illustrations show means of measuring joint motion in the lower extremity. (Reproduced from Greene
WB, Heckman JD, eds: The Clinical Measurement of Joint Motion. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 1994.)

fully extended nor fully flexed. The restricted motion is recorded as

either “The knee flexes from 30° to 90° (30° → 90°),” or “The knee
has a 30° flexion contracture with further flexion to 90° (30° FC →
90° or 30° FC W/FF 90°).”
Range of motion is slightly greater in children, particularly those
younger than 10 years. Decreased motion occurs as adults age, but the
loss of motion is relatively minimal in most joints. Except for motion
at the distal finger joints, it is safe to say that any substantial loss of
mobility should be viewed as abnormal and not attributable to aging.

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 11

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Mouth in front of the snout. Eye lateral, of moderate size. Teeth in
villiform bands, sometimes with the addition of canines; no molars or
incisor-like teeth in the jaws; palate toothless. Præoperculum
unarmed, and without bony stay. Ventrals thoracic, with one spine
and five soft rays. Bones of the head with wide muciferous channels.
Stomach coecal. Air-bladder frequently with numerous appendages
(see pp. 144 and seq.)
The fishes of the “Meagre” family are chiefly coast-fishes of the
tropical and sub-tropical Atlantic and Indian Oceans, preferring the
neighbourhood of the mouths of large rivers, into which they freely
enter, some of the species having become so completely naturalised
in fresh water that they are never found nowadays in the sea. Some
of the larger species wander far from their original home, and are not
rarely found at distant localities as occasional visitors. In the Pacific
and on the coast of Australia, where but a few large rivers enter the
ocean, they are extremely rare and, in the Red Sea, they are absent.
Many attain a large size, and almost all are eaten.
No fossil species have been as yet discovered.
Pogonias.—Snout convex, with the upper jaw overlapping the
lower. Mandible with numerous small barbels. No canines. The first
dorsal with ten stout spines. Two anal spines, the second very strong.
Scales of moderate size.
To this fish (P. chromis) more especially is given the name of
“Drum,” from the extraordinary sounds which are produced by it and
other allied Sciænoids. These sounds are better expressed by the
word drumming than by any other, and are frequently noticed by
persons in vessels lying at anchor on the coasts of the United
States, where those fishes abound. It is still a matter of uncertainty
by what means the “Drum” produces the sounds. Some naturalists
believe that it is caused by the clapping together of the pharyngeal
teeth, which are very large molar teeth. However, if it be true that the
sounds are accompanied by a tremulous motion of the vessel, it
seems more probable that they are produced by the fishes beating
their tails against the bottom of the vessel in order to get rid of the
parasites with which that part of their body is infested. The “Drum”
attains to a length of more than four feet, and to a weight exceeding
a hundred lbs. Its air-bladder has been figured on p. 146.
Micropogon is closely allied to Pogonias, but has conical
pharyngeal teeth. Two species from the western parts of the Atlantic.

Fig. 187.—Pharyngeal bones

and teeth of Pogonias chromis.
A, Upper; B, Lower pharyngeals.
Umbrina.—Snout convex, with the upper jaw overlapping the
lower; a short barbel under the symphysis of the mandible. The first
dorsal with nine or ten flexible spines, the anal with one or two. Scales
of moderate size.
 Fig. 188.—Umbrina nasus, from Panama.
Twenty species are known from the Mediterranean, Atlantic, and
Indian Ocean. One well known to the ancients, under the name of
Umbra, is the Umbrina cirrhosa of the Mediterranean, the “Umbrine”
or “Ombre” of the French, and the “Corvo” of the Italians. It ranges to
the Cape of Good Hope, and attains a length of three feet. Also on
the coasts of the United States several species occur, as U. alburna,
U. nebulosa, etc.

Fig. 189.—Umbrina nasus, from Panama.

 Sciæna (including Corvina).—The upper jaw overlapping the
lower, or both jaws equal in front. Interorbital space moderately broad
and slightly convex. Cleft of the mouth horizontal or slightly oblique.
The outer series of teeth is generally composed of teeth larger than
the rest, but there are no canines. Eye of moderate size, barbel none.

Fig. 190.—Sciæna richardsonii.

Some fifty species are known, but their distinctive characters
have been but imperfectly pointed out. They are found in all the seas
and rivers in which Sciænoids generally occur, and many are entirely
confined to fresh water, for instance the species figured, Sciæna
richardsonii, from Lake Huron; Sc. amazonica; Sc. obliqua, ocellata,
oscula, etc., from fresh waters of the United States. Sciæna
diacanthus and Sc. coitor belong to the most common fishes of the
coasts of the East Indies, ascending the great rivers for a long
distance from the sea. One of the European species, Sciæna aquila,
has an extremely wide range; it not rarely reaches the British coasts,
where it is known as “Meagre,” and has been found at the Cape of
Good Hope and on the coast of southern Australia. Like some of the
other species it attains to a length of six feet, but the majority of the
species of this genus remain within smaller dimensions. A part of the
species have the second anal ray very strong, and have been placed
into a distinct genus, Corvina,—thus, among others, Sc. nigra from
the Mediterranean, and Sc. richardsonii.
 Pachyurus is closely allied to Sciæna, but has the vertical fins
densely covered with small scales.
Otolithus.—Snout obtuse or somewhat pointed, with the lower
jaw longer. The first dorsal with nine or ten feeble spines. Canine teeth
more or less distinct. Præoperculum denticulated. Scales of moderate
or small size.
About twenty species are known from the tropical and sub-
tropical parts of the Atlantic and Indian Oceans. The air-bladder is
figured on p. 144.
Ancylodon differs from Otolithus in having very long arrow-
shaped or lanceolate canine teeth. Coasts of tropical America.
Collichthys.—Body elongate; head very broad, with the upper
surface very convex; cleft of the mouth wide and oblique; no large
canines. Eye small. No barbel. Scales small, or of moderate size. The
second dorsal very long, caudal pointed.
Three species from the East Indian and Chinese coasts. The
great development of the muciferous system on the head and the
small eye leads one to suppose that these fishes live in muddy water
near the mouths of large rivers. The air-bladder has been described
on p. 144.
Other genera belonging to this family are Larimus, Eques, Nebris,
and Lonchurus.

Fig. 191.—Histiophorus pulchellus.

 Sixth Division—Acanthopterygii Xiphiiformes.
The upper jaw is produced into a long cuneiform weapon.
These fishes form one small family only, Xiphiidæ.
The “Sword-fishes” are pelagic fishes, occurring in all tropical and
sub-tropical seas. Generally found in the open ocean, always
vigilant, and endowed with extraordinary strength and velocity, they
are but rarely captured, and still more rarely preserved. The species
found in the Indian and Pacific Oceans belong to the genus
Histiophorus, distinguished from the common Mediterranean Sword-
fish, or Xiphias, by the presence of ventral fins, which, however, are
reduced to two long styliform appendages. The distinction of the
species is beset with great difficulties, owing to the circumstance that
but few examples exist in museums, and further, because the form of
the dorsal fin, the length of the ventrals, the shape and length of the
sword, appear to change according to the age of the individuals.
Some specimens or species have only the anterior dorsal rays
elevated, the remainder of the fin being very low, whilst in others all
the rays are exceedingly elongate, so that the fin, when erected,
projects beyond the surface of the water. It is stated that Sword-
fishes, when quietly floating with the dorsal fin erect, can sail before
the wind, like a boat.
Sword-fishes are the largest of Acanthopterygians, and not
exceeded in size by any other Teleostean; they attain to a length of
from 12 to 15 feet, and swords have been obtained more than three
feet long, and with a diameter of at least three inches at the base.
The sword is formed by the prolongation and coalescence of the
maxillary and intermaxillary bones; it is rough at its lower surface,
owing to the development of rudimentary villiform teeth, very hard
and strong, and forms a most formidable weapon. Sword-fishes
never hesitate to attack whales and other large Cetaceans, and by
repeatedly stabbing these animals generally retire from the combat
victorious. The cause which excites them to those attacks is
unknown; but they follow this instinct so blindly that they not rarely
attack boats or large vessels in a similar manner, evidently mistaking
them for Cetaceans. Sometimes they actually succeed in piercing
the bottom of a ship, endangering its safety; but as they are unable
to execute powerful backward movements they cannot always
retract their sword, which is broken off by the exertions of the fish to
free itself. A piece of a two-inch plank of a whale-boat, thus pierced
by a sword-fish, in which the broken sword still remains, is preserved
in the British Museum.
The Rev. Wyatt Gill, who has worked as a missionary for many
years in the South Sea Islands, communicates that young Sword-
fishes are easily caught in strong nets, but no net is strong enough to
hold a fish of six feet in length. Specimens of that size are now and
then captured by hook and line, a small fish being used as bait.
Individuals with the sword broken off are not rarely observed. Larger
specimens cannot be captured by the natives, who are in great fear
of them. They easily pierce their canoes, and only too often
dangerously wound persons sitting in them.
The Mediterranean Sword-fish is constantly caught in the nets of
the Tunny-fishers off the coast of Sicily, and brought to market,
where its flesh sells as well as that of the Tunny.
The remarkable changes which Sword-fishes undergo at an early
stage of their growth have been noticed above, p. 173 and seq.
Sword-fishes are as old a type as the Berycoids. Their remains
have been found in the chalk of Lewes, and more frequently in the
London clay of Sheppy, where an extinct genus, Coelorhynchus, has
been recognised.

Seventh Division—Acanthopterygii Trichiuriformes.

Body elongate, compressed or band-like; cleft of the mouth wide,
with several strong teeth in the jaws or on the palate. The spinous
and soft portions of the dorsal fin and the anal are of nearly equal
extent, long, many-rayed, sometimes terminating in finlets; caudal fin
forked, if present.

Family—Trichiuridæ.
 Marine fishes inhabiting the tropical and sub-tropical seas; some
of them are surface-fishes, living in the vicinity of the coast, whilst
others descend to moderate depths, as the Berycoids. All are
powerful rapacious fishes, as is indicated by their dentition.
The oldest of the extinct genera are Enchodus and Anenchelum;
they were formerly referred to the Scombroids, but belong to this
family. The former has been found in the chalk of Lewes and
Mæstricht; the latter is abundant in the Eocene schists of Glaris.
Anenchelum is much elongate, and exhibits in the slender structure
of its bones the characteristics of a deep-sea fish; it resembles much
Lepidopus, but has some long rays in the ventrals. Other Eocene
genera are Nemopteryx and Xiphopterus. In the Miocene of Licata in
Sicily Trichiuridæ are well represented, viz. by a species of
Lepidopus, and by two genera, Hemithyrsites and Trichiurichthys,
which are allied to Thyrsites and Trichiurus, but covered with scales.
The following is a complete list of the genera referred to this
family:—
Nealotus.—Body incompletely clothed with delicate scales. Small
teeth in the jaws and on the palatine bones; none on the vomer. Two
dorsal fins, the first continuous and extending to the second; finlets
behind the second and anal fins. Each ventral fin represented by a
single small spine. A dagger-shaped spine behind the vent. Caudal fin
well developed.
One specimen only of this fish (N. tripes), 10 inches long, has
been obtained off Madeira; it evidently lives at a considerable depth,
and comes to the surface only by accident.
Nesiarchus.—Body covered with small scales. Several strong
fangs in the jaws; no teeth on the palate. First dorsal not extending to
the second. No detached finlets. Ventrals small, but perfectly
developed, thoracic. Caudal fin present. A dagger-shaped spine
behind the vent.
A rather large fish (N. nasutus), very rarely found in the sea off
Madeira. The two or three specimens found hitherto measure from
three to four feet in length. Probably living at the same depth as the
preceding genus.
 Aphanopus.—Scales none. Two very long dorsal fins; caudal well
developed; ventrals none. A strong dagger-shaped spine behind the
vent. Strong teeth in the jaws; none on the palate.
One species only is known, named A. carbo from its coal-black
colour; it is evidently a deep-sea fish, very rarely obtained in the sea
off Madeira. Upwards of four feet long.
Euoxymetopon.—Body naked, very long and thin. Profile of the
head regularly decurved from the nape to the snout, the occiput and
forehead being elevated and trenchant. Jaws with fangs; palatine
teeth present. One dorsal only, continued from the head to the caudal
fin, which is distinct. A dagger-shaped spine behind the vent. Pectoral
fins inserted almost horizontally, with the lowest rays longest, and with
the posterior border emarginate. Ventral fins rudimentary, scale-like.
This is another deep-sea form of this family, but, at present, no
observations have been made as regards the exact depth at which it
occurs. A specimen has been known since the year 1812; it was
found on the coast of Scotland, and described as Trichiurus lepturus.
The same species has been re-discovered in the West Indies,
where, however, it is also extremely scarce.
Lepidopus.—Body band-like; one single dorsal extends along the
whole length of the back; caudal well developed. Ventrals reduced to
a pair of scales. Scales none. Several fangs in the jaws; teeth on the
palatine bones.
 Fig. 192.—Lepidopus caudatus.
The Scabbard-fish (L. caudatus) is rather common in the
Mediterranean and warmer parts of the Atlantic, extending
northwards to the south coast of England, where it is an occasional
visitor, and southwards to the Cape of Good Hope. More recently it
has been observed on the coasts of Tasmania and New Zealand.
We may, therefore, justly consider it to be a deep-sea fish, which
probably descends to the same depth as the preceding allied forms.
It grows to a length of five or six feet, but its body is so much
compressed that it does not weigh more than as many pounds. It is
well known in New Zealand, where it is called “Frost-fish,” and
esteemed as the most delicious fish of the colony. A still more
attenuated species (L. tenuis) occurs in the sea off Japan, at a depth
of some 340 fathoms.
Trichiurus.—Body band-like, tapering into a fine point, without
caudal fin. One single dorsal extending the whole length of the back.
Ventrals reduced to a pair of scales, or entirely absent. Anal fin
rudimentary, with numerous extremely short spines, scarcely
projecting beyond the skin. Long fangs in the jaws; teeth on the
palatine bones, none on the vomer.
The “Hairtails” belong to the tropical marine fauna, and although
generally found in the vicinity of land, they wander frequently out to
sea, perhaps merely because they follow some ocean-currents.
Therefore they are not rarely found in the temperate zone, the
common West Indian species (T. lepturus), for instance, on the coast
of England. They attain to a length of about four feet. The number of
their vertebræ is very large, as many as 160, and more. Six species
are known.
Epinnula.—Body rather elongate, covered with minute scales,[*.
see below] The first dorsal fin continuous, with spines of moderate
strength, and extending on to the second; finlets none; ventrals well
developed. Lateral lines two. Teeth of the jaws strong; palatine teeth,
none.
The “Domine” of the Havannah, E. magistralis.
Thyrsites.—Body rather elongate, for the greater part naked. The
first dorsal continuous, with the spines of moderate strength, and
extending on to the second. From two to six finlets behind the dorsal
and anal. Several strong teeth in the jaws; teeth on the palatine
bones.
The species of this genus attain to a considerable size (from four
to five feet), and are valuable food fishes; Th. atun from the Cape of
Good Hope, South Australia, New Zealand, and Chili, is preserved,
pickled or smoked. In New Zealand it is called “Barracuda” or
“Snoek,” and exported from the colony into Mauritius and Batavia as
a regular article of commerce, being worth over £17 a ton; Th.
pretiosus, the “Escholar” of the Havannah, from the Mediterranean,
the neighbouring parts of the Atlantic, and the West Indies; Th.
prometheus from Madeira, Bermuda, St. Helena, and Polynesia; Th.
solandri from Amboyna and Tasmania is probably the same as Th.
prometheus.
Young specimens of this (or, perhaps, the following) genus have
been described as Dicrotus. In them the finlets are not yet detached
from the rest of the fin; and the ventral fins, which are entirely
obsolete in the adult fish, are represented by a long crenulated
spine.
Gempylus.—Body very elongate, scaleless. The first dorsal fin
continuous, with thirty and more spines, and extending on to the
second. Six finlets behind the dorsal and anal. Several strong teeth in
the jaws, none on the palate.
 One species (G. serpens), inhabiting considerable depths of the
Atlantic and Pacific Oceans.

Family—Palæorhynchidæ.
This family has been formed for two extinct genera:
Palæorhynchus from the schists of Glaris, and Hemirhynchus from
tertiary formations near Paris. These genera resemble much the
Trichiuridæ in their long, compressed body, and long vertical fins, but
their jaws, which are produced into a long beak, are toothless, or
provided with very small teeth. The dorsal fin extends the whole
length of the back, and the anal reaches from the vent nearly to the
caudal, which is forked. The ventrals are composed of several rays
and thoracic. The vertebræ long, slender, and numerous, and, like all
the bones of the skeleton, thin, indicating that these fishes were
inhabitants of considerable depths of the ocean. Both the jaws of
Palæorhynchus are prolonged into a beak, whilst in Hemirhynchus
the upper exceeds the lower in length.

Eighth Division—Acanthopterygii Cotto-scombriformes.

Spines developed, in one of the fins at least. Dorsal fins either
continuous or close together; the spinous dorsal, if present, always
short; sometimes modified into tentacles, or into a suctorial disk; soft
dorsal always long, if the spinous is absent; anal similarly developed
as the soft dorsal, and both generally much longer than the spinous,
sometimes terminating in finlets. Ventrals, thoracic or jugular, if
present, never modified into an adhesive apparatus. No prominent
anal papilla.
Marine fishes, with few exceptions.

First Family—Acronuridæ.
Body compressed, oblong or elevated, covered with minute
scales. Tail generally armed with one or more bony plates or spines,
which are developed with age, but absent in very young individuals.
Eye lateral, of moderate size. Mouth small; a single series of more or
less compressed, sometimes denticulated, sometimes pointed
incisors in each jaw; palate toothless. One dorsal fin, the spinous
portion being less developed than the soft; anal with two or three
spines; ventral fins thoracic. Air-bladder forked posteriorly. Intestines
with more or less numerous circumvolutions. Nine abdominal, and
thirteen caudal vertebræ.
Inhabitants of the tropical seas, and most abundant on coral-
reefs. They feed either on vegetable substances or on the superficial
animal matter of corals.
Extinct species of Acanthurus and Naseus have been discovered
in the Monte Bolca formation.
Acanthurus.—Jaws with a single series of lobate incisors, which
are sometimes movable. An erectile spine hidden in a groove on each
side of the tail. Ventral fins with one spine and generally five rays.
Scales ctenoid, sometimes with minute spines. Branchiostegals five.
The fishes of this genus, which sometimes are termed
“Surgeons,” are readily recognised by the sharp lancet-shaped spine
with which each side of the tail is armed. When at rest the spine is
hidden in a sheath; but it can be erected and used by the fish as a
very dangerous weapon, by striking with the tail towards the right
and left. “Surgeons” occur in all tropical seas, with the exception of
the eastern part of the Pacific, where they disappear with the corals.
They do not attain to any size, the largest species scarcely
exceeding a length of eighteen inches. Many are agreeably or
showily coloured, the ornamental colours being distributed in very
extraordinary patterns. The larger species are eatable, and some
even esteemed as food. It is stated that the fry of some species
periodically approaches, in immense numbers, the coasts of some of
the South Sea Islands (Caroline Archipelago), and serves as an
important article of food to the natives. Nearly fifty species are
known.
 Fig. 193.—Acanthurus leucosternum, Indian Ocean.
At an early period of their growth these fishes present so different
an aspect that they were considered a distinct genus, Acronurus.
The form of the body is more circular and exceedingly compressed.
No scales are developed, but the skin forms numerous oblique
parallel folds. The gill-cover and the breast are shining silvery.
Naseus.—Tail with two (rarely one or three) bony keeled plates on
each side (in the adult). Head sometimes with a bony horn or crest-
like prominence directed forwards. Ventral fins composed of one spine
and three rays. From four to six spines in the dorsal; two anal spines.
Scales minute, rough, forming a sort of fine shagreen. Air-bladder
forked behind. Intestinal tract with many circumvolutions.
Twelve species are known from the tropical Indo-Pacific, but
none of them extend eastwards beyond the Sandwich Islands. In
their mode of life these fishes resemble the Acanthuri. Likewise, the
young have a very different appearance, and are unarmed, and were
described as a distinct genus, Keris. One of the most common
species is N. unicornis, which, when adult (22 inches long), has a
horn about 2 inches long, whilst it is merely a projection in front of
the eye in individuals of 7 inches in length.
Prionurus is an allied genus with a series of several keeled bony
laminæ on each side of the tail.

Fig. 194.—Naseus unicornis.

Second Family—Carangidæ.
Body more or less compressed, oblong or elevated, covered with
small scales or naked; eye, lateral. Teeth, if present, conical. No
bony stay for the præoperculum. The spinous dorsal is less
developed than the soft or than the anal, either continuous with, or
separated from, the soft portion; sometimes rudimentary. Ventrals
thoracic, sometimes rudimentary or entirely absent. No prominent
papilla near the vent. Gill-opening wide. Ten abdominal and fourteen
caudal vertebræ.
 Fig. 195.—Semiophoris velitans.
Inhabitants of tropical and temperate seas. Carnivorous. They
appear first in cretaceous formations, where they are represented by
Platax and some Caranx-like genera (Vomer and Aipichthys from the
chalk of Comen in Istria). They are more numerous in various
Tertiary formations, especially in the strata of Monte Bolca, where
some still existing genera occur, as Zanclus, Platax, Caranx
(Carangopsis), Argyriosus (Vomer), Lichia, Trachynotus. Of the
extinct genera the following belong to this family:—Pseudovomer
(Licata), Amphistium, Archæus, Ductor, Plionemus (?), and
Semiophorus. Equula has been recently discovered in the Miocene
marls of Licata in Sicily.
Caranx (including Trachurus).—Body more or less compressed,
sometimes sub-cylindrical. Cleft of the mouth of moderate width. The
 first dorsal fin continuous, with about eight feeble spines, sometimes
rudimentary; the soft dorsal and anal are succeeded by finlets in a few
species. Two anal spines, somewhat remote from the fin. Scales very
small. Lateral line with an anterior curved, and a posterior straight,
portion, either entirely or posteriorly only covered by large plate-like
scales, several of which are generally keeled, the keel ending in a
spine. Dentition feeble. Air-bladder forked posteriorly.

Fig. 196.—Plates of the lateral line of Caranx hippos.

The “Horse-mackerels” are found in abundance in almost all
temperate and, especially, tropical seas. Many species wander to
other parts of the coast, or to some distance from land, and have
thus gradually extended their range over two or more oceanic areas;
some are found in all tropical seas. The species described are very
numerous, about ninety having been properly characterised and
distinguished. Some attain to a length of three feet and more, and all
are eatable. They feed on other fish and various marine animals.
Of the most noteworthy species the following may be mentioned:
—C. trachurus, the common British Horse-mackerel, distinguished
by having the lateral line in its whole length armed with large vertical
plates; it is almost cosmopolitan within the temperate and tropical
zones of the northern and southern hemispheres. C.
crumenophthalmus, C. carangus, and C. hippos, three of the most
common sea-fishes, equally abundant in the Atlantic and Indo-
Pacific oceans; C. ferdau, from the Indo-Pacific, upwards of three
feet in length. C. armatus, ciliaris, gallus, etc., which have an
exceedingly short and compressed body, with rudimentary spinous
dorsal fin, and with some of the rays of the dorsal and anal
prolonged into filaments.
 Fig. 197.—Caranx ferdau.
Argyriosus is closely allied to Caranx, especially to the last-
named species, but the lateral line has no plates whatever; and the
body is scaleless, chiefly of a bright silvery colour.

Two species from the tropical Atlantic.

Micropteryx.—Body much compressed, with prominent
trenchant abdomen, covered with small scales; lateral line not
shielded; præopercular margin entire. Cleft of the mouth rather small;
præorbital of moderate width. The first dorsal continuous, with seven
feeble spines. No detached finlets. Small teeth on the vomer and
palatine bones.

Micropteryx chrysurus is a semi-pelagic fish, and very common in

the tropical Atlantic, less so in the Indian Ocean.
Seriola.—Body oblong, slightly compressed, with rounded
abdomen, covered with very small scales; lateral line not shielded;
præopercular margin entire. Cleft of the mouth of moderate width, or
rather wide. The first dorsal continuous, with feeble spines. No
detached finlets. Villiform teeth in the jaws, on the vomer and palatine
bones.

These fishes are often called “Yellow-tails,” and occur in nearly all
the temperate and tropical seas, sometimes at a great distance from
land. Twelve species are known, and the majority have a wide
geographical range. The larger grow to a length of from four to five
feet, and are esteemed as food, especially at St. Helena, the Cape
of Good Hope, in Japan, Australia, and New Zealand.
Seriolella and Seriolichthys, the latter from the Indo-Pacific, and
distinguished by a finlet behind the dorsal and anal, are allied
genera.
Naucrates.—Body oblong, sub-cylindrical, covered with small
scales; a keel on each side of the tail. The spinous dorsal consists of
a few short free spines; finlets none. Villiform teeth in the jaws, on the
vomer and palatine bones.
The “Pilot-fish” (N. ductor) is a truly pelagic fish, known in all
tropical and temperate seas. Its name is derived from its habit of
keeping company with ships and large fish, especially Sharks. It is
the Pompilus of the ancients, who describe it as pointing out the way
to dubious or embarrassed sailors, and as announcing the vicinity of
land by its sudden disappearance. It was therefore regarded as a
sacred fish. The connection between the Shark and the Pilot-fish has
received various interpretations, some observers having perhaps
added more sentiment than is warranted by the actual facts. It was
stated that the Shark never seized the Pilot-fish, that the latter was of
great use to its big companion in conducting it and showing it the
way to its food. Dr. Meyen in his “Reise um die Erde” states: “The
pilot swims constantly in front of the Shark; we ourselves have seen
three instances in which the Shark was led by the Pilot. When the
Shark neared the ship the Pilot swam close to the snout, or near one
of the pectoral fins of the animal. Sometimes he darted rapidly
forwards or sidewards as if looking for something, and constantly
went back again to the Shark. When we threw overboard a piece of
bacon fastened on a great hook, the Shark was about twenty paces
from the ship. With the quickness of lightning the Pilot came up,
smelt at the dainty, and instantly swam back again to the Shark,
swimming many times round his snout and splashing, as if to give
him exact information as to the bacon. The Shark now began to put
himself in motion, the Pilot showing him the way, and in a moment
he was fast upon the hook.[42] Upon a later occasion we observed
two Pilots in sedulous attendance on a Blue Shark, which we caught
in the Chinese Sea. It seems probable that the Pilot feeds on the
Sharks’ excrements, keeps his company for that purpose, and
directs his operations solely from this selfish view.” We believe that
Dr. Meyen’s opinion, as expressed in his last words, is perfectly
correct. The Pilot obtains a great part of his food directly from the
Shark, in feeding on the parasitic crustaceans with which Sharks and
other large fish are infested, and on the smaller pieces of flesh which
are left unnoticed by the Shark when it tears its prey. The Pilot also,
being a small fish, obtains greater security when in company of a
Shark, which would keep at a distance all other fishes of prey that
would be likely to prove dangerous to the Pilot. Therefore, in
accompanying the Shark, the Pilot is led by the same instinct which
makes it follow a ship. With regard to the statement that the Pilot
itself is never attacked by the Shark all observers agree as to its
truth; but this may be accounted for in the same way as the impunity
of the swallow from the hawk, the Pilot-fish being too nimble for the
unwieldy Shark.
The Pilot-fish does not always leave the vessels on their
approach to land. In summer, when the temperature of the sea-water
is several degrees above the average, Pilots will follow ships to the
south coast of England into the harbour, where they are generally
speedily caught. Pilot-fish attain a length of 12 inches only. When
very young their appearance differs so much from the mature fish
that they have been described as a distinct genus, Nauclerus. This
fry is exceedingly common in the open ocean, and constantly
obtained in the tow-net; therefore the Pilot-fish retains its pelagic
habits also during the spawning season, and some of the spawn
found by voyagers floating on the surface is, without doubt, derived
from this species.
Chorinemus.—Body compressed, oblong; covered with small
scales, singularly shaped, lanceolate, and hidden in the skin. The first
dorsal is formed by free spines in small numbers; the posterior rays of
the second dorsal and anal are detached finlets. Small teeth in the
jaws, on the vomer and palatine bones.
Twelve species are known from the Atlantic and Indo-Pacific;
some enter brackish water, whilst others are more numerous at