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Orthopaedic Study Guide Series

Nikolaos K. Paschos
George Bentley Editors

General
Orthopaedics
and Basic
Science
Orthopaedic Study Guide Series
Series Editors:
Nikolaos K. Paschos
Harvard Medical School
Boston Children’s Hospital
Boston, USA

George Bentley
Royal National Orthopaedic Hospital
Stanmore, UK
Orthopaedics has many different specialisations such as trauma, spine, sports
medicine, arthroplasty, oncology, paediatric orthopaedics, hand surgery and
microsurgery to name just a few. This means that residents preparing for their
exams have a broad field to study and to remember. In addition, orthopaedics
is a surgical specialty, thus knowledge of orthopaedic techniques is necessary
and is tested during these exams. To cover all these fields and aspects of
orthopaedics, this book series has volumes dedicated to each study area and
provides a guide for all orthopaedic residents in preparation for residency and
fellowship exams.

More information about this series at http://www.springer.com/series/13489

Nikolaos K. Paschos • George Bentley
Editors

General Orthopaedics
and Basic Science
Editors
Nikolaos K. Paschos George Bentley
Harvard Medical School Royal National Orthopaedic Hospital
Boston Children’s Hospital Institute of Orthopaedics and
Boston, MA Musculo-Skeletal Science, U.C.London
USA Stanmore, Middlesex
UK

ISSN 2520-1115     ISSN 2520-1123 (electronic)

Orthopaedic Study Guide Series
ISBN 978-3-319-92191-4    ISBN 978-3-319-92193-8 (eBook)
https://doi.org/10.1007/978-3-319-92193-8

Library of Congress Control Number: 2018966999

© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword

Knowledge expands exponentially and it has been increasingly difficult for

orthopedic residents to stay abreast of the recent and meaningful advances in
this most wonderful of surgical disciplines.
Recent reports of the rising epidemic of resident burnout reflect the chal-
lenges orthopedic surgeons in training face in attempting to retain the knowl-
edge necessary not only to pass their Board Examination but also to provide
responsible care.
Nikolaos Paschos, MD, PhD, has compiled a brilliantly succinct and well-­­
organized study guide aimed at providing orthopedic residents with an essen-
tial knowledge base. This wonderfully crafted work will spare surgeons in
training needless hours of anguish as they seek to fulfill their professional
requirements.
I know Dr. Paschos well and his opus “The Orthopedic Study Guide”
reflects his true genius and mastery of basic science and general orthopedic
principles. Furthermore, this innovative publication was conceived out of the
kindness and generosity of Dr. Paschos’ heart. He is a brilliant educator with
an absolutely selfless disposition. His chief goal in the production of this
work was to lessen the burden of effective orthopedic training.
He has succeeded beyond measure.

Philadelphia, PA, USA John D. Kelly IV

v
Contents

Part I Musculoskeletal System Anatomy

1 Spine��������������������������������������������������������������������������������������������������   3
William D. Long III and Todd J. Albert
2 Pelvis and Hip����������������������������������������������������������������������������������   9
Gregory Pereira, Nikolaos K. Paschos, and John D. Kelly IV
3 Shoulder�������������������������������������������������������������������������������������������� 17
Jason Somogyi, Jonathan Twu, and J. Martin Leland III
4 Knee�������������������������������������������������������������������������������������������������� 31
Nikolaos K. Paschos and Chadwick C. Prodromos
5 Foot and Ankle Anatomy���������������������������������������������������������������� 37
Nicola Maffulli, Alessio Giai Via, and Francesco Oliva

Part II Musculoskeletal System Physiology

6 Bone Tissue Physiology�������������������������������������������������������������������� 53

Ann Marie Kelly, Nikolaos K. Paschos, Dimitrios Giotis,
and John D. Kelly IV
7 Ligament Tissue Pathology ������������������������������������������������������������ 57
Simone Cerciello and Philippe Neyret
8 Musculoskeletal System Physiology:
Ligament Tissue Physiology������������������������������������������������������������ 63
Simone Cerciello and Philippe Neyret
9 Articular Cartilage Physiology ������������������������������������������������������ 69
Ann Marie Kelly, Nikolaos K. Paschos, Dimitrios Giotis,
and John D. Kelly IV

Part III Musculoskeletal System Pathology

10 Metabolic Bone Diseases������������������������������������������������������������������ 73

Miguel Botton, António Robalo Correia,
and Manuel Cassiano Neves

vii
viii Contents

11 Orthopaedic-Related Issues with Genetic Disorders�������������������� 83

António Robalo Correia, Miguel Botton,
and Manuel Cassiano Neves
12 Infectious Diseases of the Musculoskeletal System ���������������������� 95
Theofanis Kalathas and Nikolaos K. Paschos
13 Musculoskeletal Pain Management������������������������������������������������ 105
Avraam Ploumis and Ioannis Gkiatas
14 Bone Healing������������������������������������������������������������������������������������ 111
K. Osman, Ayman Gabr, and Fares S. Haddad
15 Osteoarthritis������������������������������������������������������������������������������������ 121
Ayman Gabr, Sunil Gurpur Kini, and Fares S. Haddad
16 Inflammatory Arthropathies (Rheumatic Disorders)������������������ 133
George Bentley
17 Repair of Osteochondral Defects in the Knee by Cellular
(Chondrocyte and Stem Cell) Transplantation ���������������������������� 145
George Bentley and Panos D. Gikas
18 Heterotopic Ossification������������������������������������������������������������������ 153
Gregory Pereira, Nikolaos Paschos, and John Kelly IV
19 Metastatic Bone Tumors������������������������������������������������������������������ 159
Theofanis Kalathas and Nikolaos K. Paschos
20 Musculoskeletal Imaging Techniques�������������������������������������������� 165
Ian Pressney and Asif Saifuddin
21 Ethics������������������������������������������������������������������������������������������������ 183
Michael K. D. Benson
Contributors

Todd J. Albert Hospital for Special Surgery, New York, NY, USA
Michael K. D. Benson St Luke’s Hospital, Oxford, UK
George Bentley Institute of Orthopaedics and Musculo-Skeletal Science,
University College London, London, UK
Royal National Orthopaedic Hospital, Stanmore, UK
Miguel Botton Centro Hospitalar Lisboa Norte, Lisbon, Portugal
Simone Cerciello Casa Di Cura Villa Betania, Rome, Italy
Centre Albert-Trillat, CHU Lyon Croix-Rousse, Hospices Civils de Lyon,
Lyon, France
António Robalo Correia Department of Orthopaedic Surgery, Hospital
José Joaquim Fernandes, Beja, Portugal
Ayman Gabr Department of Orthopaedic Surgery, University College
London Hospitals, London, UK
Panos D. Gikas Bone Tumour Unit, Royal National Orthopaedic Hospital
NHS Trust, Stanmore, UK
Royal National Orthopaedic Hospital, Stanmore, UK
Dimitrios Giotis Panepistimion Ioanninon, Department of Orthopaedic
Surgery, Ioannina, Greece
Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia,
PA, USA
Ioannis Gkiatas Departments of Orthopaedics and PMR, University of
Ioannina, Ioannina, Greece
Fares S. Haddad Institute of Sport, Exercise & Health, University College
Hospital, London, UK
Theofanis Kalathas Department of Internal Medicine, Boston Medical
Center, Boston, MA, USA
Ann Marie Kelly Department of Orthopedic Surgery, University of
Pennsylvania, Philadelphia, PA, USA

ix
x Contributors

John D. Kelly IV Department of Orthopedic Surgery, University of

Pennsylvania, Philadelphia, PA, USA
Sunil Gurpur Kini Department of Orthopaedics, Manipal Hospitals,
Bangalore, India
William D. Long III Orthopedic Spine & Sports Medicine Center, Paramus,
NJ, USA
Nicola Maffulli Department of Musculoskeletal Disorders, School of
Medicine and Surgery, University of Salerno, Salerno, Italy
Queen Mary University of London, Barts and the London School of Medicine
and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital,
London, UK
J. Martin Leland III University Hospitals Geauga Medical Center and UH
Solon/Twinsburg/Streetsboro Health Centers, Cleveland, OH, USA
Manuel Cassiano Neves Hospital CUF Descobertas, Lisbon, Portugal
Philippe Neyret University Lyon 1, La Tour-de-Salvagny, France
Centre Albert-Trillat, CHU Lyon Croix-Rousse, Hospices Civils de Lyon,
Lyon, France
Francesco Oliva Department of Orthopaedic and Traumatology, University
of Rome “Tor Vergata”, School of Medicine, Rome, Italy
K. Osman School of Biosciences, University of Birmingham, Birmingham,
UK
Nikolaos K. Paschos Division of Sports Medicine, Department of
Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School,
Boston, MA, USA
Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia,
PA, USA
Gregory Pereira Department of Orthopedic Surgery, University of
Pennsylvania, Philadelphia, PA, USA
Avraam Ploumis Departments of Orthopaedics and PMR, University of
Ioannina, Ioannina, Greece
Ian Pressney Department of Radiology, The Royal National Orthopaedic
Hospital Trust, Stanmore, Middlesex, UK
Chadwick C. Prodromos Illinois Sports Medicine and Orthopaedic Center,
Glenview, IL, USA
Department of Orthopedic Surgery, Rush University Medical Center,
Chicago, IL, USA
Asif Saifuddin Department of Radiology, The Royal National Orthopaedic
Hospital Trust, Stanmore, Middlesex, UK
Contributors xi

Jason Somogyi Carl R. Darnall Army Medical Center, Fort Hood, TX, USA
University Hospitals: Geauga Medical Center, Cleveland, OH, USA
Jonathan Twu Department of Orthopedic Surgery, University of Chicago,
Chicago, IL, USA
University Hospitals, Geauga Medical Center, Cleveland, OH, USA
Alessio Giai Via Department of Orthopaedic and Traumatology, University
of Rome “Tor Vergata”, School of Medicine, Rome, Italy
 Part I
Musculoskeletal System Anatomy
 Spine
1
William D. Long III and Todd J. Albert

Case Examples ion with complete resolution of his pain by

2 weeks postoperatively.
51-Year-old male presents to the office with a 47-Year-old female presents for evaluation of
2-month history of severe pain originating in his severe pain and dysfunction in her left upper
low back. The pain travels down the posterior extremity. She works as a hairstylist, and has
aspect of his thigh down into the bottom of his been unable to perform her duties at work due to
foot. The pain is associated with subjective complaints of pain and weakness in her wrist.
numbness and a sensation of pins and needles Her symptoms began 6 weeks ago after suffering
across the lateral aspect of his foot. He notes a fall while walking her dog, landing hard on her
weakness in his “calf” muscle. Conservative left knee and jarring her neck. She describes the
measures initiated by his primary care physician pain as a burning down her left arm starting from
6 weeks ago included nonsteroidal anti-­ her shoulder and ending at her thumb and index
inflammatories, a Medrol dose pack, and physi- finger. It is associated with subjective weakness
cal therapy. Lumbar epidural injections performed in her left wrist. Physical therapy, nonsteroidal
by a physiatrist 2 weeks ago failed to provide any anti-inflammatories, and narcotic medications
relief of his symptoms. Physical examination of failed to provide relief. Physical examination
the patient showed subjective numbness along showed a positive Spurling’s sign to the left, with
the plantar aspect of the foot, 4/5 strength in numbness of the left thumb to pinprick, and 4/5
ankle plantar flexion, and an inability to heel strength in the left wrist extensors. Brachioradialis
raise ten times on the right. A MRI of the lumbar reflex was 1+, with a negative Hoffman’s sign.
spine revealed a herniated intervertebral disc at MRI of the cervical spine shows a herniated
the L5–S1 level, causing severe right-sided S1 nucleus pulposus at C5–6 causing left-sided
nerve root compression (Fig. 1.1). The patient foraminal stenosis and C6 nerve root compres-
underwent a right-sided L5–S1 microdiscectomy, sion (Fig. 1.2). The patient underwent an anterior
and recovered 5/5 strength in ankle plantar flex- cervical decompression and fusion, with resolu-
tion of her left-sided pain but persistent numb-
W. D. Long III ness in the thumb at 4 weeks.
Orthopedic Spine and Sports Medicine Center,
Paramus, NJ, USA
e-mail: LongW@hss.edu
T. J. Albert (*)
Hospital for Special Surgery, New York, NY, USA
e-mail: Albertt@hss.edu

© Springer Nature Switzerland AG 2019 3

N. K. Paschos, G. Bentley (eds.), General Orthopaedics and Basic Science, Orthopaedic Study
Guide Series, https://doi.org/10.1007/978-3-319-92193-8_1
4 W. D. Long and T. J. Albert

Fig. 1.1 T2-weighted axial and sagittal cuts from an MRI of the lumbar spine showing a right-sided herniated interver-
tebral disc at the L5–S1 level

Fig. 1.2 T2-weighted sagittal and axial cuts from an MRI of the cervical spine showing a left-sided herniated interver-
tebral disc (yellow arrow) at the C5–6 level

Main Topics • Chondrification and ossification occur

Embryology of the Spine
• The vertebral column is formed from 42 to 44
somites that ultimately differentiate into ven-
tromedial sclerotomes and dorsolateral
dermomyotomes.
• Sclerotomes develop into definitive vertebrae,
causing myotomes to bridge the intervertebral
spaces, and this permits movement of the
spine.
between days 40 and 60, leading to the forma-
tion of distinct vertebral units.
• Caudal cells from the sclerotome migrate
to form the annulus fibrosus, and a regress-
ing notochord forms the nucleus
pulposus.
• The posterior elements of the spine are formed
from cells adjacent to the neural tube that
form the vertebral arches.
• Vertebral unit morphology is regulated by the
HOX family of genes.
1 Spine
• The neural elements of the spine are formed
from the notochord, which is formed by day
18 of gestation from migrating epiblasts fol-
lowing gastrulation.
Functional Spinal Unit (FSU)
• The FSU is the smallest physiological motion
unit of the spine, consisting of two adjacent
vertebrae, the intervertebral disc, and all
adjoining ligaments between them.
• The basic bony anatomy of a vertebra can be
broken into three sagittal columns: anterior,
middle, and posterior.
• The anterior column consists of the anterior
half of the vertebral body.
• The middle column consists of the posterior
half of the vertebral body and pedicle, includ-
ing the level of the canal.
• The posterior column is made up of the facet
joints, laminae, and spinous processes.
• The anterior longitudinal ligament (ALL) cov-
ers the anterior aspect of the vertebral bodies
and limits spinal extension.
• The posterior longitudinal ligament (PLL)
covers the posterior aspect of the bodies and
limits spinal flexion.
• The ligamentum flavum connects the laminae
of adjacent vertebrae from the axis to the first
segment of the sacrum.
• Interspinous ligaments connect the spinous
processes, acting as a posterior tension band
preventing spinal flexion.
Craniovertebral Junction
• The craniovertebral junction is comprised of
the base of the occiput, the atlas (C1), and the
axis (C2).
• Primary stability is achieved through the sup-
porting ligamentous complex that spans the
bony architecture.
• The apical, alar, cruciate ligaments as well as
the tectorial membrane prevent abnormal
motion between the three articulations.
5
• Fifty percent of flexion and extension of the
neck occurs at the articulation of the occiput
and atlas.
• Fifty percent of rotation of the neck occurs at
the atlantoaxial joint.
• The vertebral artery courses through the trans-
verse foramen of C2 and C1 before penetrating
the atlanto-occipital membrane and becoming
intradural.
• C1 vertebra has no body or spinous process, and
the superior concave articular surfaces accom-
modate the occipital condyles of the skull.
• C2 vertebra has a traditional vertebral body
with the projecting odontoid process, the site
of multiple ligamentous attachments to the
ring of C1; it has distinct pedicles and pars as
well as a large spinous process.
Cervical Spine
• The subaxial cervical spine includes C3
through C7.
• The normal posture of the cervical spine is
one of lordosis, approximately 15–25°.
• There are eight cervical nerve roots, each tak-
ing off and coursing above the corresponding
pedicle (e.g., the C7 root takes off above the
C7 pedicle, while the C8 roots take off below
the C7 pedicle).
• The anterior tubercle of the C6 transverse pro-
cess is frequently palpable and used as an ana-
tomic landmark for incision placement, and is
commonly called the carotid or Chassaignac
tubercle.
• The hyoid bone is commonly at the level of
C3, while the thyroid cartilage corresponds to
C4, and the cricoid at C6.
• The spinal canal is triangular with a larger lat-
eral compared to anteroposterior dimension.
• The uncovertebral joints are identified along the
lateral aspect of the endplates and assist to define
the margin for discectomy or corpectomy.
• The cervical plexus is comprised of the ante-
rior rami of C1 to C4.
• The brachial plexus is comprised of the ante-
rior rami of C5 to T1.
6 W. D. Long and T. J. Albert

• The vertebral arteries originate from the sub- • The pars interarticularis is the region between
clavian and enter the transverse foramen of C6. the superior and inferior articulating facets, a
• The carotid sheath houses the carotid artery, fracture of which is termed spondylolysis, and
the internal jugular vein, and the vagus nerve. can occur in 5–6% of the population.
• The spinal cord ends at the conus medullaris,
typically at the level of the L1 body or L1–L2
Thoracic Spine disc; caudal to this nerve roots descend within
the thecal sac as the cauda equina.
• The thoracic spine is composed of 12 rib-­ • Posterolateral disc herniations compress the
bearing vertebrae with occasional enumerat- traversing nerve root at the lateral recess of the
ing variations. spinal canal, prior to reaching the interverte-
• The thoracic cage commonly limits motion of bral foramen; this results in compression of
the thoracic spine secondary to the osteoliga- the inferior nerve root; hence a L4–5 disc
mentous relationship of the ribs and vertebrae. compresses the L5 nerve root.
• The normal posture of the thoracic spine is • Far lateral disc herniations compress the ceph-
one of kyphosis, approximately 10–40° with alad exiting nerve root close to the superior
an apex at T7. pedicle; hence a L2–3 disc would compress
• Vertebral body morphology demonstrates a the L2 nerve root.
wedge shape with the posterior height being • Facet joint and ligamentum flavum hypertrophy
greater than the anterior, facilitating the secondary to degeneration can lead to stenosis
kyphotic posture of this region. at the lateral recess and intervertebral foramen.
• Thoracic facet joints are intermediately ori- • The lumbosacral plexus is comprised of the
ented compared to the cervical (coronal) and ventral rami from the T12 though S3 nerve
lumbar (sagittal) spine, offering stability roots, and travels posterior to the psoas.
through both flexion and extension. • The sciatic nerve arises from the ventral rami
• The diameter of the spinal canal is less than of L4 through S3, with a preaxial tibial divi-
that of the cervical and lumbar spine. sion and postaxial peroneal division.
• Nerve roots at each level exit below their cor- • The main blood supply to the region comes
responding pedicle; hence the T5 nerve root from the segmental arteries arising from the
exits below the T5 pedicle. lumbar, iliolumbar, and median sacral arteries.
• Nerves innervate the thorax and abdomen, • The bifurcation of the aorta and inferior vena
with T4 at the level of the nipples and T10 at cava commonly occurs at the level of the L4–5
the level of the umbilicus. disc space.
• The artery of Adamkiewicz provides the main • The erector spinae is composed of the iliocos-
blood supply to the cord from T8 to the conus, talis, longissimus, and spinalis muscles, and is
with segmental arteries from the lumbar and responsible for extension and lateral rotation
intercostal arteries supplying the remainder. of the vertebral column.

Lumbar Spine Sacroiliac Spine

• The lumbar spine is typically comprised of
five vertebras, with occasional counting
anomalies due to a sacralized L5 or lumbari-
zed S1 vertebra.
• Compared with the cervical and thoracic
spine, the spinal canal and bony architecture
are much larger in diameter.
• Five sacral vertebrae fuse to form the wedge-­
shaped kyphotic sacrum.
• The coccyx is formed from four fused coc-
cygeal vertebras, possibly the remnant of a
tail.
• The sacrum distributes force to the pelvis
through the paired large vertical sacroiliac
1 Spine
(SI) joints, a true synovial diarthrodial joint
that has negligent motion.
• The pelvic splanchnic nerves arise from the S2
through S4 nerve roots, supplying autonomic
innervation to the abdominal and pelvic viscera.
• The bulbocavernosus reflex also involves the
S2 to S4 nerve roots, and is the lowest measure-
able spinal reflex, useful for spinal cord trauma.
• The median sacral artery supplies the lower
lumbar vertebra, sacrum, and coccyx.
• The posterior SI ligaments are thicker and
more robust than the anterior SI ligaments.
• The sacrotuberous and sacrospinous liga-
ments attach the sacrum to the ischial tuberos-
ity and ischial spine, respectively, delineating
the greater and lesser sciatic foramen.
Neural Elements
• The cross-sectional anatomy of the spinal
cord is divided among ascending and
Fig. 1.3 ASIA worksheet for documenting individual motor and sensory nerve root function based on level
7
d­ escending tracts that allow for the transmis-
sion of stimuli to and from the brain.
• The dorsal root (sensory) and ventral root
(motor) coalesce to form the paired spinal
nerves at each level of the spine.
• The spinal cord is covered in three protective
sheaths, from deep to superficial: pia mater,
arachnoid mater, and dura mater.
• Cervical nerve roots C5 through T1 are
responsible for innervation of the upper
extremities in a myotomal and dermatomal
pattern, while the five lumbar and first
sacral nerve roots supply the lower
extremities.
• The lower 11 thoracic nerve roots have less of
a motor role, providing sensation to the thorax
and abdomen.
• The American Spinal Injury Association
(ASIA) provides a guide for the myotomal
and dermatomal innervation of the body based
on nerve root level (Fig. 1.3).
8 W. D. Long and T. J. Albert

Questions (a) T1
(b) T10
Which of the following statements is true? (c) T12
(d) T4
(a) Cervical nerve roots come off the spinal cord (e) T8
below their corresponding pedicle, and lum-
bar nerve roots come off above their corre- What superficial anterior landmark can be
sponding pedicle. ­palpated to approximate the level of C4?
(b) Both cervical and lumbar nerve roots come
off above their corresponding pedicle. (a) Thyroid cartilage
(c) Cervical nerve roots come off the spinal (b) Hyoid bone
cord above their corresponding pedicle, (c) Sternocleidomastoid muscle
and lumbar nerve roots come off below (d) Carotid tubercle
their corresponding pedicle. (e) Carotid pulse
(d) Both cervical and lumbar nerve roots come
off below their corresponding pedicle. A right-sided far lateral disc herniation at
L4–5 would be expected to produce what signs
At which level is the conus medullaris typi- and symptoms?
cally found?
(a) Right-sided quadriceps weakness, pain
(a) Foramen magnum extending down to the top of the foot.
(b) C7–T1 (b) Left-sided foot drop, left-sided numbness
(c) T7–T10 over the dorsum of the foot.
(d) L1–L2 (c) Bilateral hallux extension weakness, numb-
(e) L5–S1 ness at the right foot first webspace.
(d) Right-sided ankle dorsiflexion weakness,
The sensation of the abdomen and back at the pain down into the front of the leg.
level of the umbilicus corresponds to what tho- (e) Right-sided hip extension weakness, numb-
racic level? ness over the lateral aspect of the leg.
 Pelvis and Hip
Gregory Pereira, Nikolaos K. Paschos,
and John D. Kelly IV
Anatomy
The pelvis is formed by the two innominate
bones that articulate posteriorly at the sacrum
and anteriorly at the pubic symphysis. These
attachments form the pelvic girdle, which links
the axial skeleton to the lower extremities of the
body. Each innominate bone is formed by the
fusion of the ischium, ilium, and ischium that
occurs during puberty. The fusion of these three
bones forms cup-shaped, anteverted (15°) acetab-
ulum that articulates with the head of the femur
to form the diarthrodial hip joint.
Pelvic articulations have limited intrinsic sta-
bility. Instead, key ligaments of the posterior,
anterior, and pelvic floor complex provide stabil-
ity to the pelvis and resist deforming stresses.
The complex consists of the sacroiliac and ilio-
lumbar ligaments that prevent nutation and coun-
ternutation and are among the strongest ligaments
in the body. The anterior complex includes the
G. Pereira (*) · J. D. Kelly IV
Department of Orthopedic Surgery, University of
Pennsylvania, Philadelphia, PA, USA
e-mail: Gregory.Pereira@uphs.upenn.edu
N. K. Paschos
Department of Orthopedic Surgery, University of
Pennsylvania, Philadelphia, PA, USA
Division of Sports Medicine, Department of
Orthopaedic Surgery, Boston Children’s Hospital,
Harvard Medical School, Boston, MA, USA
e-mail: Nikolaos.Paschos@childrens.harvard.edu
© Springer Nature Switzerland AG 2019
N. K. Paschos, G. Bentley (eds.), General Orthopaedics and Basic Science, Orthopaedic Study
Guide Series, https://doi.org/10.1007/978-3-319-92193-8_2
2
fibrocartilaginous pubic symphysis and resists
external rotation. The pelvic floor complex
includes the sacrospinous ligament that resists
external rotation and the sacrotuberous ligament
that resists shear and flexion.
The hip has conferred stability from the bony
articulation of the femoral head in the acetabu-
lum. Additionally, the fibrocartilaginous labrum
increases the acetabular depth, and offers an
attachment site for the adjacent ligaments,
increasing joint stability. Finally, the hip capsule
composed of the iliofemoral, ischiofemoral, and
pubofemoral ligaments contributes to the stabil-
ity of the hip joint. The iliofemoral ligament is
the strongest of the three ligaments and resists
anterior dislocation and hyperextension. The
ischiofemoral ligament, the only ligament located
in the posterior hip, resists excessive internal
rotation, extension, and posterior translation.
Finally the pubofemoral ligament on the anterior
aspect of the hip resists excessive abduction and
extension.
Hip Arthroscopy
Setup
• Patient positioned in supine or lateral decubi-
tus position.
• Requires traction (25–50 lbs) in line with the
femoral neck.
9
10 G. Pereira et al.

Portals • Requires disruption of the abductor

mechanism.
• Anterolateral portal • Complications: damage to obturator nerve,
–– Used as the primary viewing portal and for medial femoral circumflex artery, deep exter-
anterolateral access. nal pudendal artery.
–– Incorrect placement risks damage to supe-
rior gluteal nerve.
• Anterior portal Medial Approach
–– Placed with hip flexed in internal rotation.
–– Used for anterior access. • Provides excellent exposure to the psoas.
–– Incorrect placement risks damage to lateral • Complications: damage to the LFCN and fem-
femoral cutaneous nerve (LFCN). oral nerve.
• Posterior/posterolateral portal
–– Used for posterior access.
–– Incorrect placement risks damage to sciatic
nerve. Direct Lateral Approach (Hardinge)
• Distal anterolateral portal (may not be used
depending on indication) • Commonly used in THA.
–– Used to access the peripheral compartment. • Requires split of gluteus medius and vastus
–– Traction must be removed and hip is placed lateralis.
in neutral flexion/extension. • Complications: superior gluteal nerve and
femoral nerve injury.
The reported complication rate for hip arthros-
copy is between 1.3 and 6.4%. The most common
complications from hip arthroscopy are transient  osterior Approach (Moore or
P
neuropraxias of the pudendal and peroneal nerve. Southern)
These injuries may be prevented with intermit-
tent release of traction. • Provides excellent exposure to acetabulum
and proximal femur.
• Requires release of the short external
Surgical Approaches to the Hip Joint rotators.
• Complications: injury to sciatic nerve, infe-
Anterior Approach (Smith Peterson) rior gluteal artery, superior gluteal artery/
nerve.
• Provides excellent exposure to the ilium.
• Requires ligation of the lateral femoral cuta-
neous artery.
• Complications: damage to the LFCN and fem- Pelvic Ring Injury
oral nerve.
General

 nterolateral Approach (Watson

A • Mechanism: high-energy blunt trauma.
Jones) • High mortality rates ranging from 15 to
50%.
• Provides excellent exposure to the acetabulum • Hemorrhage is he major cause of death in
and proximal femur. these cases.
2 Pelvis and Hip 11

Anatomy Classification

• Pelvic ring is composed of the sacrum and the • Tile classification

two innominate bones. • Young-Burgess Classification
• Must be disruption of the ring in at least two
places if displacement occurred.
• Stability is reliant on the ligamentous struc- Complications
tures in the pelvis (anterior, posterior, and pel-
vic floor complex). • DVT (~60%) and PE (27%)
• Posterior ligaments are in close proximity to • Urogenital injury (12–20%)
key neurovascular structures (e.g., internal • Chronic instability (rare)
iliac artery, lumbosacral plexus).

 ecent Developments in Pelvis/Hip

R
Exam Anatomy

• Inspection: look for abnormal lower extremity • A recent retrospective review studied sacral frac-
rotation, ecchymosis, limb length discrepancy, tures in the setting of pelvic ring injuries. Sacral
lacerations, flank hematoma. fractures were seen in 60% of pelvic trauma
• Neurologic exam: assess lumbosacral patients. Of these fractures, avulsion fractures
plexus. and longitudinal fractures of the sacrum are
• Urogenital: vaginal, rectal exam, assess urine almost always associated with anterior pelvic
for gross hematuria. ring injury. Conversely, the study found that
• Stability: gentle rotational force on each iliac transverse fractures of the lower sacrum and
crest (perform one time only). combined longitudinal and transverse sacral
fractures are prone to occur in isolation.
• The direct anterior approach (DAA) to the hip
Imaging for total hip arthroplasty (THA) has been
growing in popularity in recent years. The rate
Critical to look for signs of radiographic of revision after DAA versus non-anterior
instability: approaches to the hip is a rather unexplored
field. A recent study comparing DAA versus
1. Avulsion fracture (sacrum, ischial spine, non-anterior approaches found that the mean
ischial tuberosity, transverse process of the duration from primary DAA THA to revision
fifth lumbar vertebrae). THA was 3.0 ± 2.7 years versus 12.0 ± 8.8
2. Sacral gap fracture. years for non-anterior approaches. Aseptic
3. >5 mm displacement of posterior sacroiliac loosening of the stem was found to be signifi-
complex. cantly more common in DAA THA (P < 0.001)
than in non-anterior approach THA leading to
The imaging to request for suspected pelvic earlier revision procedures.
ring injury: • Hip arthroscopy has grown in popularity
but outcome data from patient-reported
• AP pelvis metric and patient satisfaction scores are
• Inlet view not frequently reported. A recent study
• Outlet view evaluated 2-year patient-reported outcome
• CT pelvis scores and patient satisfaction scores after
12 G. Pereira et al.

hip arthroscopy using pre- and postopera- (C) Infection

tively four PRO measures: (D) Hemorrhage

–– The modified Harris Hip Score (mHHS) What should you perform on this patient as
–– Non-Arthritic Hip Score (NAHS) part of the physical exam?
–– Hip Outcome Score-Activities of Daily
Living (HOS-ADL) I. Rectal exam
–– Hip Outcome Score-Sport-Specific II. Vaginal exam
Subscale (HOS-SSS) III. Oral exam
IV. Neurological exam of the lower extremities
At 2-year follow-up all scores showed statisti- (A) I
cally significant improvements (P < .0001) in (B) I, II
all measures. As such, this study concluded that (C) I, III
primary hip arthroscopy had excellent clinical (D) I, II, IV
outcomes and patient satisfaction at short-term (E) II, III, IV
follow-up validating its use in recent years.
Name two radiographic indications of pelvic
• Each approach to the hip has strengths and instability:
weaknesses but minimizing loss of strength to
the hip after THA might allow for faster recov- 1. Sacral gap fracture
ery. A recent study compared leg press and 2. >5 mm displacement of posterior sacroiliac
abduction strength pre- and postoperatively in complex
patients undergoing THA with three different 3. Avulsion fracture (sacrum, ischial spine,
approaches (direct lateral, posterior, or ante- ischial tuberosity, transverse process of the
rior approach). Follow-up was conducted up fifth lumbar vertebrae)
to 3 months postoperatively. In the first post-
operative week the posterior and anterior What is the most common complication of
approaches produced significantly less pelvic ring fracture?
decrease in muscular strength than the direct
lateral approach. However, at 3-month follow- (A) Urologic injury
­up there were no differences in leg press and (B) DVT
abduction strength between any of the groups. (C) Chronic instability
(D) Vaginal vault prolapse

Case Studies
Case 1
A 28-year-old female presents to the emergency
department after a motor vehicle collusion in which
he was the passenger. He is arousable but a poor his-
torian. On exam, he is noted to have multiple lacera-
tions around his trunk and pelvis and flank hematoma.
His left leg appears to be externally rotated.
What is the major cause of death in pelvic ring
injury patients?
(A) Fat embolism
(B) Air embolism
Case 2
A 46-year-old man with a MRI-confirmed labral
tear is referred to you for labral repair. He is in
good health, clears preoperative evaluation, and
is scheduled for surgery.
The patient is concerned about complications
of arthroscopy and asks what the most common
complication is. What do you respond?
(A) Transient neuropraxia of pudendal or
peroneal nerve
(B) LFCN nerve injury
(C) Injury to the labrum
2 Pelvis and Hip 13

When positioning the patient traction should • Direct lateral approach (Hardinge)
be in line with which anatomic structure? • Posterior approach (Moore or Southern)

(A) Femoral head To emulate native anatomy how should the

(B) Femoral neck cup be placed?
(C) Femoral shaft
(D) Acetabulum (A) Anteverted
(B) Retroverted
What is the order the portals should be placed? (C) Neutral version

(A) Anterior, posterior, anterolateral What is the strongest ligament in the hip capsule?
(B) Posterior, anterior, anterolateral
(C) Anterolateral, anterior, posterior (A) Pubofemoral ligament
(D) Anterior, anterolateral, posterior (B) Iliofemoral ligament
(C) Ischiofemoral ligament
What nerve is most at risk to be injured with
improper positioning of the posterior portal? What ligament of the hip capsule resists
_____________________________ (sciatic nerve) excessive internal rotation, extension, and poste-
What is the mechanism for pudendal and pero- rior translation?
neal nerve injuries in hip arthroscopy?
_________________________ (traction injury) (A) Pubofemoral ligament
(B) Iliofemoral ligament
(C) Ischiofemoral ligament
Case 3

A 68-year-old man with crippling osteoarthritis Review Questions

presents to your clinic. He has had multiple corti-
costeroid and visco-supplementation injections
with no relief of symptoms. Radiographs show
bone on bone wear, joint space narrowing, and
prominent osteophytes. You counsel the patient
on the treatment options and he decides to
undergo total hip arthroplasty.
Which of the following structures confer sta-
bility to the native hip?
I. Hip capsule
II. Obturator internus
III. Labrum
(A) I
(B) I, II
(C) I, III
(D) II, III
Name three approaches to the hip that may be
used for THA?
• Anterior approach (Smith Peterson)
• Anterolateral approach (Watson Jones)
In a THA with a direct anterior approach what are
the two most commonly injured structures?
(A) LCFN, sciatic nerve
(B) LCFN, femoral nerve
(C) Medial femoral circumflex artery
(D) Obturator nerve, femoral nerve
What approach to the hip is most likely to
injure the obturator nerve?
(A) Direct lateral approach (Hardinge)
(B) Anterolateral approach (Watson Jones)
(C) Anterior approach (Smith Peterson)
(D) Posterior approach (Moore or Southern)
Which of the following statements is true?
(A) There must be disruption of the ring in at
least two places if displacement occurred.
(B) Bony articulation is the primary source of
stability of the pelvis.
14 G. Pereira et al.

(C) The anterior complex ligamentous structures (E) Posterior approach

are stronger than the posterior complex
ligaments. Which of the following nerves is at risk of
(D) The Garden classification is the most common being damaged during hip arthroscopy if the
system used to classify pelvic ring fractures. anterior portal is incorrectly positioned?

What approach requires release of the short (A) Femoral nerve

external rotators? (B) Sciatic nerve
(C) Obturator nerve
(A) Anterolateral approach (D) LFCN
(B) Anterior approach
(C) Posterior approach What ligamentous complex structures in the
(D) Medial approach pelvis resist external rotation, shear, and exces-
sive flexion?
Incorrect placement of the anterolateral portal
in hip arthroscopy is most likely to injure what (A) Posterior complex
structure? (B) Anterior complex
(C) Pelvic floor complex
(A) Femoral nerve
(B) Lateral femoral circumflex artery
(C) Lateral femoral cutaneous nerve Further Readings
(D) Sciatic nerve
(E) Obturator nerve Alwattar BJ, Bharam S. Hip arthroscopy portals. Oper
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What is the normal version of the acetabulum? Beckmann N, Cai C. CT characteristics of traumatic
sacral fractures in association with pelvic ring inju-
ries: correlation using the Young-Burgess classifica-
(A) 30° of retroversion tion system. Emerg Radiol. 2017;24(3):255–62.
(B) 15° of retroversion Bentley G, editor. European surgical orthopaedics
(C) 15° of anteversion and traumatology: the EFORT textbook. Berlin,
Heidelberg: Springer; 2014.
(D) 30° of anteversion Byrd JWT. Hip arthroscopy utilizing the supine position.
Arthroscopy. 1994;10(3):275–80.
What approach to the hip is most likely to Byrd JWT. Hip arthroscopy. J Am Acad Orthop Surg.
damage the sciatic nerve and the inferior gluteal 2006;14(7):433–44.
Chang CY, Huang AJ. MR imaging of normal hip
artery? anatomy. Magn Reson Imaging Clin N Am.
2013;21(1):1–19.
(A) Anterior approach Cole JD, Blum DA, Ansel LJ. Outcome after fixation of
(B) Anterolateral approach unstable posterior pelvic ring injuries. Clin Orthop
Relat Res. 1996;329:160–79.
(C) Medial approach Dickson KF. Pelvic ring injuries. In: Surgical treatment
(D) Lateral approach of orthopedic trauma. New York, NY: Thieme; 2007.
(E) Posterior approach p. 448–53.
DiGioia AM, Plakseychuk AY, Levison TJ,
Jaramaz B. Mini-incision technique for total
What approach to the hip provides optimal hip arthroplasty with navigation. J Arthroplast.
exposure to the psoas? 2003;18(2):123–8.
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(A) Anterior approach intervention. 2nd ed. New York: McGraw Hill;
2008.
(B) Anterolateral approach Eto S, et al. The direct anterior approach is associated
(C) Medial approach with early revision total hip arthroplasty. J Arthroplast.
(D) Lateral approach 2017;32(3):1001–5.
2 Pelvis and Hip
Gautier E, Ganz K, Krügel N, Gill T, Ganz R. Anatomy
of the medial femoral circumflex artery and
its surgical implications. J Bone Joint Surg Br.
2000;82(5):679–83.
Gupta A, et al. Does primary hip arthroscopy result
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cal follow-­up on a mixed group of 738 consecu-
tive primary hip arthroscopies performed at a
high-volume referral center. Am J Sports Med.
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Hardinge K. The direct lateral approach to the hip. Bone
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Hughes PE, Hsu JC, Matava MJ. Hip anatomy and bio-
mechanics in the athlete. Sports Med Arthrosc Rev.
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Meneghini RM, et al. Muscle damage during MIS total
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WJ. Muscle damage during MIS total hip arthro-
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 Shoulder
3
Jason Somogyi, Jonathan Twu,
and J. Martin Leland III

Osseous [1–5] –– Acromion

Four ossification centers (basi, meso, meta,
• Scapula and pre-acromion).
–– Seventeen muscle attachments, four liga- Three types of morphology (I—flat, II—
mentous attachments. curved, III—hooked).
–– Scapular plane is 30° anterior to coronal plane. –– Suprascapular notch
–– Glenoid Covered by the superior transverse scapu-
Retroverted 5° compared to scapular plane. lar ligament.
Supraglenoid tubercle—origin of long Suprascapular Artery runs over ligament
head of biceps. (“Army OVER the bridge”).
–– Scapular spine Suprascapular Nerve runs under ligament
Separates supraspinatus and infraspinatus. (“Navy UNDER the bridge”).
–– Coracoid Compression here will paralyze the supra-
Attachments for ligaments (coracoacro- spinatus and infraspinatus.
mial and coracoclavicular), conjoined ten- –– Spinoglenoid notch
don and pectoralis minor. Suprascapular artery and nerve run around
Used as anterior landmark for surgical notch.
approaches and injections. Compression here will only paralyze the
infraspinatus.
J. Somogyi, M.D. • Clavicle
University Hospitals: Geauga Medical Center, –– Fulcrum for lateral movement of arm.
Cleveland, OH, USA
–– First bone to ossify (5-week fetal) and last
Carl R. Darnall Army Medical Center, to fuse (medial epiphysis—25 years).
Fort Hood, TX, USA
• Humeral head
J. Twu, M.D. –– Retroverted 30° from transepicondylar axis
University Hospitals: Geauga Medical Center,
Cleveland, OH, USA
of distal humerus.
–– Neck shaft angle is 130°.
Department of Orthopedic Surgery, University of
Chicago, Chicago, IL, USA
–– Greater tuberosity (supraspinatus, infraspi-
natus, teres minor) and lesser tuberosity
J. Martin Leland III, M.D. (*)
University Hospitals Geauga Medical Center and UH
(subscapularis) are attachments for rotator
Solon/Twinsburg/Streetsboro Health Centers, cuff.
Cleveland, OH, USA

© Springer Nature Switzerland AG 2019 17

N. K. Paschos, G. Bentley (eds.), General Orthopaedics and Basic Science, Orthopaedic Study
Guide Series, https://doi.org/10.1007/978-3-319-92193-8_3
18 J. Somogyi et al.

–– Long head of the biceps runs through the
bicipital groove (pectoralis major inserts
just lateral to the groove, latissimus dorsi
just medial to the groove).
Joint [1–5]
• Range of motion
–– Forward flexion: 0–170°
–– Extension: 0–60°
–– Abduction: 0–170°
2:1 ratio of glenohumeral joint to scapulo-
thoracic motion during abduction.
Full abduction requires external rotation to
clear acromion.
–– Internal rotation: 70°
–– External rotation: 80°
–– MGHL: resists anterior and posterior trans-
lation in midrange abduction (45°) and
external rotation (ER).
–– IGHL:
Posterior band: restrains posterior sublux-
ation at 90° of flexion/abduction and inter-
nal rotation (IROT) as well as 90° of
external rotation.
Anterior band: restrains anterior sublux-
ation at 90° of flexion/abduction and inter-
nal rotation as well as 90° of external
rotation.
Superior band: most important static
stabilizer.
• Coracoacromial ligament (CAL)
–– Important for superoanterior restraint in
rotator cuff deficiencies (should be pre-
served when debriding massive cuff
tears).

Labrum

• Creates cavity compression and 50% of the

glenoid socket depth.
• Fibrocartilaginous tissue that receives blood
supply from capsule and periosteal vessels.
• Anchors:
–– Anteroinferior labrum anchors the infe-
rior glenohumeral ligament: leads to
Bankart lesion (anteroinferior labral
tears; can be boney or non-boney) in dis-
location events.
–– Superior labrum anchors long head of
biceps tendon: associated with SLAP (supe-
rior labrum anterior to posterior) lesions.
• Anatomic variants:
–– Sublabral foramen.
–– Buford complex.
Ligamentous restraints
Arm Anterior Inferior Posterior
Ligamentous Stability position restraint restraint restraint
Neutral SGHL
• Three main glenohumeral ligaments: superior 45 ER MGHL
45 ABD
(SGHL), middle (MGHL), and inferior
90 ER IGHL IGHL IGHL
(IGHL): Ant band Ant band Post band
–– Act as static stabilizers of the shoulder. 90 FF IGHL IGHL
–– SGHL: restrains inferior translation at 0° of 90 ABD Ant band Post band
abduction (neutral). 90 IR
3 Shoulder 19

Muscles • Shoulder internal rotators are stronger than the

• Rotator cuff muscles (supraspinatus, infraspi-
natus, teres minor, and subscapularis), deltoid,
and teres major act on the shoulder:
–– Cuff muscles stabilize humeral head
against glenoid (dynamic stabilizers).
external rotators (this is why electrocution/sei-
zures lead to posterior shoulder dislocations).
• Long head of biceps originates from superior
glenoid and labrum; held in groove via the
transverse humeral ligament as well as the
subscapularis tendon.

Muscles of the shoulder

Muscle Origin Insertion Action Innervation
Deltoid Clavicle, acromion Deltoid tuberosity Abduction Axillary n.
Supraspinatus Superior dorsal Greater tuberosity Abduction and Suprascapular n.
scapula ER
Infraspinatus Inferior dorsal scapula Greater tuberosity ER Suprascapular n.
Teres minor Scapula Greater tuberosity ER Axillary n.
Subscapularis Ventral scapula Lesser tuberosity IR Upper + lower subscapular n.
Pectoralis Sternum, ribs, clavicle Intertubercular IR and Medial + lateral pectoral n.
major groove adduction

Neurovascular Supplies motor to subscapularis and teres

• Arteries
–– Ascending branch of anterior humeral cir-
cumflex artery
Supplies humeral head; runs parallel and
lateral to long head of biceps.
–– The arcuate artery
Interosseous continuation of ascending
branch; penetrates humeral head.
–– Posterior humeral circumflex artery
Recent literature supports this as main
blood supply to humeral head.
–– Acromial branch of thoracoacromial artery
Runs on the medial aspect of the coracoacro-
mial ligament, a common cause of bleeding
during subacromial arthroscopy.
• Nerves
–– Suprascapular nerve
Comes off upper trunk of brachial plexus,
C5–C6 fibers.
Runs under ligament in suprascapular and
spinoglenoid notch.
Supplies motor to supraspinatus and
infraspinatus.
–– Upper and lower subscapular nerve
Comes off posterior cord of brachial
plexus, C5–C6 fibers.
major.
–– Medial pectoral nerve
Comes off medial cord of brachial plexus,
C8–T1 fibers.
Pierces pectoralis minor to supply motor
for pectoralis minor and major.
–– Axillary nerve
Innervation: motor for deltoid and teres
minor; sensory to lateral shoulder.
Origin: off posterior cord of brachial
plexus, C5–C6 fibers.
Travels posteriorly behind the surgical
neck of humerus with posterior circumflex
humeral artery through the quadrangular
space and then curves anteriorly 5–7 cm
inferior to the acromion.
Surgical Approaches [5–20]
• Arthroscopic portals
–– Posterior
Primary viewing portal.
2 cm inferior and 1 cm medial to postero-
lateral corner of acromion.
Passes through infraspinatus or between
infraspinatus and teres minor.
20 J. Somogyi et al.

–– Anterior –– Space for olecranon process in full

Lateral to coracoid process and anterior to extension.
the AC joint. (b) Radial head
Passes between pectoralis major and • Stabilizer against valgus stress.
deltoid. • 280° covered by cartilage:
–– Lateral –– Safe zone for fixation of fracture:
1–2 cm distal to lateral edge of acromion. –– 90–110° arc from radial styloid to
Passes through deltoid. Lister’s tubercle with arm neutral.
• Anterior approach (deltopectoral) (c) Proximal ulna
–– Deltopectoral groove and coracoid as • Olecranon
landmark. • Greater sigmoid notch
–– Deltoid (axillary) and pectoralis major –– Articulates with trochlea.
(medial and lateral pectoral nerve) • Lesser sigmoid notch
interval. –– Articulates with radial head.
–– Dangers: musculocutaneous nerve, • Coronoid
cephalic vein, axillary nerve. –– Buttress to prevent posterior
• Lateral approach (deltoid split) subluxation.
–– No internervous plane. –– Loss of >50% of height →
–– Split deltoid inferior to acromion; do not instability.
go more than 5 cm inferior to the acromion • Sublime tubercle
(due to location of axillary nerve). –– Insertion of anterior bundle of ulnar
• Posterior approach collateral ligament.
–– Use acromion and scapular spine as (d) Carrying angle
landmark. • Angle between long axis of humerus and
–– Teres minor (axillary nerve) and infraspi- ulna:
natus (suprascapular nerve) interval. –– Measured in frontal plane with elbow
–– Dangers: suprascapular nerve and axillary extended.
nerve. • 11–14° in men.
• 13–16° in women.

Elbow Anatomy
Joint
Osseous
• Ulnohumeral articulation = hinge.
(a) Distal humerus • Radiohumeral articulation = pivot.
• Lateral epicondyle • Radioulnar = rotation.
–– Origin of lateral collateral ligament • Maximum capsule distension at 70–80°:
complex. –– Patients with effusion most comfortable in
–– Origin of extensor/supinator mass. this position.
• Medial epicondyle • Normal capsular volume = 25 mL.
–– Origin of medial ulnar collateral • Capsule attaches 6 mm distal to tip of
ligament. coronoid
–– Origin of flexor/pronator mass. –– Coronoid is intra-articular structure; can be
• Trochlea visualized during arthroscopy.
–– Medial and spool shaped. • Range of motion
• Capitellum –– 0–145° Flexion/extension.
–– Lateral and hemispherical. –– 90° Supination.
• Olecranon fossa –– 80° Pronation.
Another random document with
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 "Yes, faith, I shall creep down."

They left Huntingdon together, Jacob walking by Winter's horse for two
miles. They parted, then, in the gracious glow of evening, and the elder sat
upon a shelf of rock and waited. Far beneath him the sun fires lingered over
the pavilions of a larch grove and warmed the young green to gold. The
untiring cuckoo called a while, then grew silent as twilight stole delicately
over all things and detail died.

He saw Auna at last—slim and swift, ascending on quick feet. And then
she had come, put her arms round his neck, kissed him, and looked into his
eyes with the warmth of her steadfast worship.

"Is your soul quiet now, dear father?" she asked; and he replied:

"Yes, faith, it's quiet now, my dinky maid."

She sighed with satisfaction.

So they went up together, hand in hand, through the cool curtain of

dusk; with fret of light and shadow all vanished for that day. They went up
speaking very few words into the deepening bloom of night, while on the
sky glimmered the stars again, and in the grass a glow-worm. From his
stony place among the fern, churn-owl throbbed a lullaby for the whole,
drowsy earth; and he touched their human hearts, old and young, with the
mystery of his music—the mystery of all living songs that waken when the
rest of the world is going to sleep. The two notes whirred on, rising and
falling, fainting and trembling out again.

Then the white face of Huntingdon looked upon them.

"It shan't be your home much longer—I promise that," he whispered;

but as yet Auna knew no other love than love of him.

"Where you are is my home, father," she said.

PRINTED IN GREAT BRITAIN BY WOODS & SONS, LTD., LONDON, N.1
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