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Orthopaedics and Traumatology: The Essential Guide is a completely new textbook in the English language, but has a long history in the Netherlands. For physicians and medical students, physiotherapists and students, general practitioners and orthopaedic nurses: this textbook has been the main source of orthopaedic knowledge for decades.

Orthopaedics and Traumatology: The Essential Guide deals with the diagnosis and treatment of the most common disorders of the musculoskeletal system, both surgical and non-surgical. It is made up of four sections: basic knowledge, traumatology, orthopaedics in children and adult orthopaedics. To make studying easier, the text is interspersed with interludes, key points and more than 500 illustrations. All authors are experts in their fields.

Lower back pain and other musculoskeletal disorders are among the disorders with the greatest burden of disease. This burden will increase with the continued ageing of our global population. However, orthopaedic disorders and injuries can occur not only in the elderly, but at any age. They may cause disability, reduce quality of life and sometimes lead to loss of independence. As a result, the costs to society are high. Fortunately, there is an increasing number of successful treatment options.

When treating orthopaedic and trauma patients, close cooperation and efficient communication is essential between doctors of different medical specialities, between primary and secondary care, and between doctors and paramedics. We expect this book to be invaluable in medical and paramedical training.

The complete book is available online with access to embedded videos and deep links. You can also test your new competencies and knowledge using case studies and tests at the end of each chapter.

Inhoudsopgave

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Basic Knowledge

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1. Physical examination

Summary
Orthopaedics is the medical specialty aimed at improving or maintaining the function of the entire musculoskeletal system. The aim is for the patient to be able to carry out all the activities they need or wish to do. The orthopaedic surgeon diagnoses, treats and restores disorders of the musculoskeletal system – including the spinal column – and also pays attention to prevention. The disorders relate to dysfunction, changes in shape and damage to bones, cartilage, joints, capsules, ligaments, muscles and tendons.
J. A. N. Verhaar, J. B. A. van Mourik

2. Applied anatomy of the human musculoskeletal system

Summary
Thorough knowledge of anatomy has traditionally been a prerequisite for the practice of medicine and surgery. At the time of Vesalius (1514–1564), anatomy was the ‘mainstream’ of medicine, but even at the beginning of the twenty-first century, it has lost none of its relevance. In fact, ‘good old’ anatomy has taken on new dimensions through advanced imaging techniques, such as CT and MRI, and through new approaches, such as endoscopic surgery. Three-dimensional knowledge of the body is indispensable for a correct interpretation of the images obtained.
G. J. Kleinrensink, R. Stoeckart

3. Orthopaedic diagnostic tests

Summary
The most important tool in the diagnosis and choice of treatment of orthopaedic disorders is medical history taking (anamnesis). Good medical history taking often leads to the correct diagnosis in a significant number of patients. The physical examination should further support this preliminary diagnosis, but the importance of a good medical history cannot be emphasised enough. Diagnostic tests (laboratory studies or imaging techniques such as X-rays) only come last in diagnostic cascade. The choice of treatment is based on the severity of the symptoms, but also on professional and personal settings. The burden of the treatment and the chance of a successful treatment must also be taken into account. This is a delicate weighing process, guided by the increasing number of evidence-based guidelines or appropriate use recommendations.
J. A. N. Verhaar

4. Treatment techniques in orthopaedics

Summary
In orthopaedics, the treatment spectrum is broad. The surgical treatment is part of this, but despite the vastly increased surgical options, the non-surgical (‘conservative’) treatment is still very important. Conservative treatment may include an explanation of the complaints to the patient, advice on how to handle them, physiotherapy, cast treatment, use of braces, prescribing painkillers and administering local injections. However, there are many other forms of treatment. A considerable number of these treatment options have an empirical basis, which sometimes leads to conflicting insights. In recent years, scientific research has shown that a number of previously applied treatments are ineffective or no better than a placebo. The best-known of these are various physical therapy modalities, including cryotherapy, thermotherapy, ultrasound and electrotherapy. Glucosamine tablets for osteoarthritis have also proved to be ineffective. Of the surgical treatments, arthroscopic rinsing of an osteoarthritic joint has turned out to be no better than placebo surgery.
J. A. N. Verhaar

5. Physiotherapy and rehabilitation medicine

Summary
The physiotherapist and other paramedics play an important role in the treatment of musculoskeletal disorders and injuries. This applies not only to non-surgical (conservative) treatment but also perioperative treatment. The aim of the treatment is to support the patient returning to the highest possible level of functioning. In some patients, this is only possible with mobility aids. In patients with rheumatoid arthritis and foot abnormalities, for example, orthotic footwear is necessary. The orthopaedic shoemaker and the orthotic technicians (who, after amputations, provides prostheses, among other things) have considerable knowledge about the measurement and production of these mobility aids.
J. A. N. Verhaar

Traumatology

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6. General trauma care: Advanced Trauma Life Support

Summary
The initial work-up and treatment of trauma patients has undergone many changes in the last decades. The principles of ATLS (Advanced Trauma Life Support) are generally accepted in Europe. After an accident, in most cases an emergency call is made to a central emergency call centre. There, an estimate of the help required at the place of the accident is made. Based on the accident description, it can be estimated whether it involves a high or low energy trauma mechanism.
M. Holla

7. General principles for the treatment of orthopaedic trauma

Summary
Fractures naturally tend to heal spontaneously. Fracture healing is strongly related to vascularisation and stability. The functional result after healing depends on the position and localisation of the fracture. The goal of fracture treatment is to obtain fracture healing and restoration of function. The main treatment methods are divided into conservative and surgical options. The different treatments consist of applying traction, applying an external splint such as a plaster cast or an external fixator or applying an internal fixation with plates, screws and/or nails. In recent decades, surgical treatment methods have gained in popularity and therefore the development of these methods has gained momentum. Their popularity is mainly due to the possibility of functional anatomical recovery while maintaining joint mobility, during which the patient is not bedridden for long periods of time. An important development in surgical fracture treatment in the twentieth century has been the better understanding of the treatment of the accompanying soft tissue injury. For example, at the beginning of the twentieth century the treatment of an open fracture consisted of amputation. With the implementation of extensive debridement, the introduction of antibiotics, the use of tissue-friendly implants and the early reconstruction of soft tissue by tissue transposition, the treatment goal has shifted from vitality to maintaining function and infection prevention.
G. M. M. J. Kerkhoffs

8. Sports injuries

Summary
Mobility and movement are essential for life: ‘motion is life and life is motion’. Adequate exercise has a beneficial effect on health, preventing many diseases. The savings on medical consumption resulting from this preventive effect in general exceed the costs caused by sports injuries.
D. E. Meuffels

9. Dancers’ and musicians’ injuries

Summary
Dancers and musicians, both professionals and amateurs, place high and specific demands on their bodies and are therefore injury-prone. Intense, prolonged practice and training are required in order to be able to provide artistic excellence for audiences and the media. In dance, maximum proprioception and coordination are essential, and in music, extreme precision and control of fine motor skills – both accompanied by great stamina. In a symphony, the fingers of a violinist run a true marathon; in a piano concerto, the same applies to a pianist.
A. B. M. Rietveld

10. Spinal injuries

Summary
Traumatic spinal injuries (TSI) are events that impact patient’s physical, psychological and social well-being. The overall global incidence of TSI is 10.5 cases per 100,000 people; TSI are responsible for 5,000 patient admissions to Dutch hospitals each year, around 200 of them with neurological involvement. Spinal column injuries are usually the result of traffic or work accidents. Other causes are sports accidents and falls from significant heights (both by choice or accidentally).
F. C. Öner

11. Injuries of the upper extremity

Summary
Injuries of the upper extremities occur relatively frequently. Looking just at fractures, the incidence is highest in the upper extremity. The upper extremities are vulnerable for fractures during accidents at home, work and in traffic. Because the upper extremities have many important mechanical functions, injuries to the arms require maximum attention and commitment from the practitioner. Loss of these sophisticated functions will lead to serious disability.
M. Holla

12. Injuries to the acetabulum, pelvis and lower extremity

Summary
Traumatic injuries of the lower extremity are very common in general practice, in traffic, during sports and at work. Every doctor is therefore regularly confronted with such injuries, or their residual consequences. Many simple injuries, such as an ankle distortion, can be treated in the first line. The emphasis in this chapter is on the most common injuries, in which especially the fracture treatment is discussed. Less common injuries are also discussed to provide insight into the general principles of treatment and the specific complications that may occur. Injuries of the pelvis are less common but are potentially life-threatening and are therefore also discussed here.
M. Heeg, P. Kloen

13. Fractures in children

Summary
This chapter systematically deals with the diagnosis and treatment of bone fractures that occur in children. A general introduction will describe the development of the skeleton. Damage to the developing children’s skeleton, and in particular to the growth plates, can have major consequences on the final shape and function of the impacted bone(s). The general treatment principles, in which a well-padded plaster cast is used after the reduction, followed by a close-fitting immobilising bandage, actually apply to all fracture treatments. Extra attention to information provided by the parents is essential here; the younger child cannot indicate when a bandage is too tight or whether, for example, a nerve is pinched. Most fractures in children, possibly after reduction, can and should be treated conservatively, because screw fixation nearby a growth plate can cause potential damage. Because children are still growing, axis deviations are often (but not always) corrected spontaneously. However, this does not apply to rotation errors and larger shaft deviations. Partly because of this, surgical fixation of fractures has been increasingly performed in recent years. By using a temporary fixation, often with K-wires, but sometimes also with plate osteosynthesis, the reduction is better maintained during the healing phase. The orthopaedic (trauma) surgeon is often the first to see children with injuries that may have been caused through child abuse. Often these fractures have specific characteristics, but alertness in general to the risk is vital.
S. K. Bulstra

Orthopaedics for children

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14. Congenital and acquired general abnormalities in children

Summary
In this chapter a number of generalised congenital abnormalities are discussed, together with acquired abnormalities, such as leg length difference and rotational disorders of the lower extremities.
M. Heeg

15. Shoulder, elbow, forearm and wrist/hand abnormalities in children

Summary
The development of the upper extremity starts with the outgrowth of the limb bud in the fourth week of pregnancy when the embryo is 4 mm long. In this limb bud, which consists of mesoderm, cartilage, neuromuscular structures and vascular structures develop. At 8 weeks, this differentiation process is well advanced. Malfunctions in this process, genetic or acquired, result in (combinations of) malformations.
J. A. van der Sluijs

16. Spine disorders in children and adolescents

Summary
Children grow and develop over time. The development over time of a certain condition is known as its ‘natural history’. This means that, without treatment, the condition improves spontaneously, remains unchanged or worsens. Knowledge of the natural history of the various growth disorders of the spine is important in order to be able to decide on a prognosis and be able to determine the (need for) different treatment options. A disorder with a mild natural history, with a chance of spontaneous improvement or low risk of progression, can of course often be treated very hesitantly. If, on the other hand, if it is almost certain that waiting will lead to a considerable deterioration of the existing situation, with sometimes a worse final result from treatment, it is much better to opt for timely and sometimes ‘aggressive’, possibly surgical, intervention.
R. M. Castelein

17. Hip disorders in children

Summary
Disorders of the hip in children can have a significant impact on the quality of life during childhood and lead to progressive degenerative abnormalities of the hip by young adulthood and later in life. It is therefore important to detect hip abnormalities in time and treat them adequately. In this chapter, the most common, as well as some rare disorders of the paediatric hip that require adequate treatment are discussed. With the help of a thorough and complete history and physical examination, one is able to arrange systematically a broad differential diagnosis (also incorporating less obvious causes). Because pain in the hip region is not always caused by a condition of the hip in a narrower sense, disorders that may cause more or less similar symptoms such as limping and groin pain will also be highlighted in the differential diagnosis.
J. H. J. M. Bessems

18. Lower leg and knee disorders in children

Summary
The various knee and lower leg abnormalities and deformities seen in general practice are often linked to different age periods. A distinction can also be made between congenital abnormalities and deformities that occur during growth. The congenital abnormalities are relatively rare. The majority of variations in axis and length are seen during growth. Some of these variations are physiologic and will normalise during growth. In this chapter the more frequently occurring abnormalities and deformities at different ages are discussed. The most important learning objective is to distinguish between abnormalities and deformities for which a ‘wait and see’ policy is appropriate, and those that need referral to a certified centre of expertise.
R. J. B. Sakkers

19. Foot and toe disorders in children

Summary
A ‘foot problem’ in a child is an important reason for an orthopaedic consultation. It is important to realise that the foot problem can be a local abnormality as an expression of a larger and more extensive problem. That is why it is of the utmost importance to start with a general physical examination, with emphasis on the hips and spine. Obtaining an exploratory impression of the neurological status is also a standard part of this examination. Any underlying suffering (e.g. spina bifida, Duchenne’s disease, hereditary motor and sensory neuropathy (HMSN), spinal tumours) has a greater impact than the foot problem itself.
P. G. M. Maathuis

General orthopaedics

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20. Osteoarthritis

Summary
Osteoarthritis is characterised by loss of hyaline cartilage in a part of a synovial joint, together with changes in the (subchondral) bone directly beneath the cartilage and an inflammatory reaction of the synovial membrane of that joint. Osteoarthritis is further characterised by joint pain after loading, stiffness of the joint and restriction of movements. If the cause of osteoarthritis is not clear, one speaks of primary or idiopathic osteoarthritis. The condition can also occur after a distinct cause (infection or trauma) and then we speak of secondary osteoarthritis.
J. A. N. Verhaar, J. B. A. van Mourik

21. Surgical treatment options in rheumatoid arthritis

Summary
Rheumatoid arthritis (RA) is a chronic inflammatory systemic disease (autoimmune disease) with an unknown cause, mainly located in the synovium of the joints (video).
R. G. H. H. Nelissen

22. Metabolic bone diseases

Summary
The skeleton clearly has a large number of mechanical functions. It protects vital structures, and muscles and tendons are firmly attached to the bone. Our hard bones also form a very active organ. Bone is constantly broken down and rebuilt. Approximately 10 % of bone tissue is renewed each year. The bone is also an important reservoir of minerals. A large number of endocrine factors are involved in the control of bone remodeling. The calcium and phosphate balance is partly regulated by the bone, and diseases that affect this balance also have an indirect effect on the shape and firmness of the bone.
P. L. A. van Daele, M. C. Zillikens

23. Bone and joint infections

Summary
Clinically relevant infections of bones and joints only concern bacterial infections. These conditions can lead to permanent consequences for the patient. It is important to start treatment as soon as possible, which means that adequate recognition of septic conditions is important. Osteomyelitis is more common than septic arthritis. Both conditions can occur spontaneously, especially in children or the elderly. In developing countries, the prevalence is higher. Osteomyelitis and arthritis can occur separately, but also in combination.
J. G. E. Hendriks

24. Tumours and tumour-like lesions of bone and soft tissues

Summary
Many types of tumours occur in the skeleton and soft tissue. The tumours that develop in close relation to the skeleton are called primary bone tumours. Fortunately, the majority of these bone and soft tissue tumours are benign. If they are malignant, they are referred to as bone sarcoma. The biological behaviour of bone tumours, both benign and malignant, varies greatly, with tumour growths ranging from inactive or barely active to extremely active (tab. 24.1). This characterisation in general explains the clinical presentation. For example, in indolent, benign bone tumours there are seldom complaints, whereas in an aggressive benign bone tumour, complaints are to be expected. The diagram in tab. 24.2 shows a general classification and this already shows the great diversity. Officially, we distinguish > 168 forms of bone and soft tissue tumours.
P. D. S. Dijkstra, M. A. J. van de Sande

25. Disorders of the shoulder

Summary
The shoulder consists of three bone fragments: the scapula, the clavicle and the humerus, surrounded by a joint capsule and a number of muscles providing stability and guiding movement (including the four muscles of the rotator cuff, the deltoid muscle and the pectoralis major muscle) (fig. 25.1). Typically, a relatively large sphere (humeral head) articulates on a small, almost flat contact surface (glenoid). As a result, a large freedom of movement exists, but also potential instability.
R. G. H. H. Nelissen

26. Disorders of the elbow, forearm, wrist and hand

Summary
The elbow, forearm, wrist and hand are the parts of the musculoskeletal system that are essential for functioning at a higher motor level. Injuries, both as a result of trauma and from chronic strain, are relatively common in this region and have a major impact on the quality of life. Recognition of the symptoms and knowledge of the natural course, form the basis for good treatment. Adjusting activities often already leads to recovery. In this chapter, an anatomical classification has been chosen, from elbow via forearm to wrist, hand and fingers, in which the most common conditions are discussed per location. The aim of this chapter is to provide adequate insight into these common disorders, their natural course and the effectiveness of the various treatment methods on the outcome and the patient’s ultimate functioning.
R. L. Diercks

27. Disorders of the hip joint

Summary
Osteoarthritis of the hip joint, usually referred to as coxarthrosis, is common (‘coxa’ means hip). The incidence of osteoarthritis of the hip in Europe is difficult to determine, but it is a real burden to its societies. Many people with mild symptoms fitting osteoarthritis do not seek medical help. Hip osteoarthritis is more common in women than in men. Based on demographic developments, it is expected that the absolute number of people with osteoarthritis who consult a GP will increase by 52 % between 2007 and 2040. If a future increase of (severe) overweight (an important risk factor for osteoarthritis) is also taken into account, the prevalence of osteoarthritis will increase even more in the future.
B. W. Schreurs

28. Disorders of the knee

Summary
Because of its function and construction, the knee joint is one of the body’s most heavily loaded joints. It has great mobility with low intrinsic stability. In fact, the knee joint is really just a sphere (femur condyles) on a plate (tibia plate). The limited intrinsic stability must be compensated for by strong static ligaments (collateral ligaments and cruciate ligaments) and a strong dynamic stabilisation by powerful muscle groups on the ventral side (m. quadriceps) and on the dorsal side (hamstring group) of the upper leg. The leverage and twisting forces acting on the knee can be so great that the stabilising forces cannot neutralise them completely resulting in ligament and meniscal injuries. In addition, osteoarthritis of the knee occurs frequently. As a result, knee joint disorders frequently occur and are often seen in both general and orthopaedic practice. In this chapter, the most relevant disorders are discussed.
J. A. N. Verhaar

29. Foot and ankle disorders

Summary
During their lifetime, the average human walks three times around the world. Usually, one does not realise how important the foot is until problems with it exist. These usually arise when the balance between the intrinsic quality of the foot and load or stress on the foot is disturbed. A mild change of foot structure without consequences for most people, can cause complaints in an athlete who runs 100 kilometres a week.
J. W. K. Louwerens

30. Disorders of the thoracolumbar spine in adults

Summary
The centre of the skeleton is the spine, which is indispensable to our existence. In evolution, the human spine is unique. Because we walk on two feet without a stabilising tail, our spine stands vertically. Partly because of this, the spine is susceptible to many pathological disorders. This vulnerability, combined with our western lifestyle (factors related to reduced general health; obesity, lack of exercise, smoking) causes around 50 % of the adult population to have back problems with some regularity. Back complaints are one of the most frequent occurring reasons for temporal or permanent disability to work, loss of productivity and (according to research by the World Health Organisation (WHO)), cause of the greatest social costs (the ‘global burden of disease’) in the western world (higher than either cardiovascular diseases or cancer).
B. J. van Royen, M. de Kleuver

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