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Dr. Armando Caldas - M.D. Orthopaedic Surgeon
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Brief History of Orthopedics Part 2: from the twentieth century to the present

we have previously approached the early history of the treatment of orthopedic injuries, which culminated in his individualization as a medical specialty throughout the nineteenth century.
The century that succeeded it was however that that faster progress provided to this medical specialty and so, early in the twentieth century, in 1902, Albin Lambotte, a Belgian surgeon developed the concept of external fixation creating a model composed of a frame where are fit metal pins set in both bone tops, constituting a direct ancestor of those who today are used as the first choice in the treatment of open fractures. Additionally, he developed in 1907 a pin to fix the trochanteric fractures and in 1909 its own system of plates and screws, and was the first to use the term osteosynthesis reflecting the correct and stable fixation of fractures.
One of methods of fractures treatment still used is its fixation with steel wire cables joining the bone tops under tension, known as "cerclage", a technique that had a large increase with Italian surgeon Vittorio Putti in 1914.
The attempt to observe directly the joint cavities took the first steps in 1917 with the Japanese Kenji Takagi, being the Swiss Eugen Bircher the first to apply the technique using laparoscopic devices in 1920.
The infection resulting from colonization by microbial organisms has always been one of the e most feared complications of surgical procedures and one of the most terrible complications of open fractures, something that changed radically in a positive way with the discovery of penicillin by Alexander Fleming in 1928.
As treatment of orthopedic tuberculosis complications, Robert Girdlstone was the first to create in 1926 a joint plasty repairing the joint by the resection of the femoral head, leaving the free cavity filled with scar tissue cretaing a pseudarthrosis, giving rise to a false joint with acceptable function.
As already happened before with the American Civil War, the two great world wars of the twentieth century drove the creation of innovative treatments that give the best answer to the various problems caused by the large number of traumatized, leading to that in the full World War II a German surgeon named Gerhard Kuntcher revolutionized the treatment of fractures through the creation of a metallic endomedular rod placed in the central part of the bone, allowing a more rapid recovery of such lesions in order to promote an early return to the front of war of highly skilled soldiers such the airline pilots.
After the war, in the mid-twentieth century, it began to be developed by Austin T. Moore some implants for joint replacement as a treatment for the osteoarthritis, a concept that continues to evolve since then.
The Russian surgeon Gavril Ilizarov developed in 1951 a special type of external fixation based on circular rings and wires to treat complex open fractures, non-unions, and that also allows to make the bone lengthening.
In order to promote the development of new techniques of fixation, a group of surgeons joined in Switzerland in 1958 to form an association known as A.O., standardizing its treatment with the creation of a classification for fractures and establishing a set of procedures which still form the basis for its treatment.
The fact of seeking the best results with less aggression to the body, combined with the growing of technological developments, led to the creation of the minimally invasive surgery, and Masaki Watanabe was one of the precursors of the modern arthroscopy, developing a new model arthroscope in 1959.
As the range of knowledge expands due to increasingly detailed knowledge of the intricacies of the human body, associated to the growing of development of the technological possibilities for the diagnosis and treatment of orthopedics lesions, the knowledge became too broad to encompass alone an increasing number of variables, so that, as in line with other branches where is divided Medicine, also was need a walk towards the sub-specialization existing today surgeons increasingly dedicated entirely to only one area of pathology, such as the spine, the hand, the hip, the knee, or the foot, believing that with the focus of experience in highly differentiated professionals is possible achieve better results than trying to embrace a growing body of knowledge in a diffuse manner.

Brief History of Orthopaedics Part 1: from antiquity to the twentieth century

The term Orthopedics has been widely attributed to a French doctor named Nicolas Andry that first used it in the mid-eighteenth century to describe the treatment of skeletal deformities in children, resulting from the joining of two terms of Greek origin, "Orthos" which meant straight and "Paeidion", meaning child.
Fractures are a fatality inherent in the stage of evolution that led to the first rigid skeletons always when they suffer high loads ahead of his resistence, usually accidental,  causing disability, often fatal to the injury victim's.
Once the human being has a bony skeleton, we can assume that the history of fractures is intertwined with the history of humanity, and its former treatment was initially intuitive, revealing the most ancient finds that the initial treatments would consist of wooden splints attached to the fractured limb, as does reveals the finding of early human fossils on which are met sequelae of aligned fractures.
In a relatively recent period of our history there were found immobilizers similar to splints on mummies, being the application of plastered immobilization chronologically later, apparently associated with the Persian culture.
Hippocrates, the father of medicine was in the fifth century BC the first to describe the immobilization with splints and Galen, considered the father of Anatomy, was in the second century, the first to mention the importance of traction for appropriate reduction of the fractures.
The plastered immobilization gave a great evolutionary leap in the tenth century when it appears for the first time described a type of plaster more easily moldable and with faster drying, known as plaster of Paris by virtue of being widely used in buildings in that area.
Obtaining a correct alignment of the various bone fragments was was not always easy and to help to solve this problem Gersdof at the beginning of the sixteenth century (1517) created an external wood tutor to align and immobilize fractures, later improved in 1758 by Benjamin Goch, who created a functional immobilizer that allowed some joint mobility while consolidating fractures.
Amboise Paré is an unavoidable name of the History of Medicine and Orthopedics also owes his tribute, particularly in the treatment of open fractures, usually associated with high mortality, by introducing the concept of surgical debridment, with cleaning, washing and removal of foreign bodies as fundamental steps to improve the prognosis.
By the nineteenth century Orthopaedics did not exist as individual entity, being just only one branch of Surgery and was during this century that began to gain the right to be considered a medical specialty, probably thanks to emerging devices and techniques that made possible a large increase in the treatment of fractures.
It was in this century, in 1843 that the French surgeon Joseph Malgaigne introduced an innovative concept for the treatment of fractures when invented an external hook that bring bone tops kept together, particularly in the case of the patella fractures, being the first known example of an external fixator. On the other hand, in 1851, the Dutch surgeon Antonius Mathysen created a plaster bandage similar to those that are used today.
The treatment of fractures of the major bones of the lower limbs was always a difficult challenge to solve favorably, something that has changed noticeably when Owen Thomas created in the mid-nineteenth century, 1875, a traction system to treat conservatively the fractures of the femur and the leg bones.
The unpredictability of getting a good consolidation of fractures sparked interest in the surgical approach to achieve the correct reduction and fixation on direct control, leading Hansmann to created in 1885 the screwed plate, a concept that continues valuable today.
The invention of the X-Ray by Wilhelm Rongten in 1895 was another major step towards modern Orthopedics, enabling the display of skeletal parts as they are within the structures that surround them, giving great help in the diagnosis and treatment of bone lesions.
The British Orthopaedic Society was created in 1894 by Sir Robert Jones who years later wrote the first book dedicated to Orthopedic Surgery.

Muscular Dystrophies

We have already discussed the impact caused in Orthopedics by diseases that affect the central or the peripheral nervous system.
There is a group of relatively rare of diseases that affect one of the majors components of the locomotor system, the muscles, leading to its progressive degeneration and partial replacement by connective or adipose tissue.
There are essentially three types of muscle tissue, the Smooth Muscle, associated with internal visceral organs, the Skeletal Muscle, associated with joint movement induced by its contraction, causing the voluntary movements, and finally the Cardiac striated Muscle, existing in the heart.
Muscular Dystrophies comprise a group of diseases with hereditary nature and are generally progressive and characterized by lack of muscle strength and they are accentuated over time and can be detected in early childhood or become apparent only in adulthood.
Clinically we can find, in addition to progressive muscle weakness, difficulty to contain saliva, to smile or to raise the eyelids, muscle atrophy, difficulty in walking, as well as cardiac or respiratory diseases.
Muscular Dystrophies are associated with various orthopedic pathologies that we stands out the Scoliosis, or the muscle contractures or decreased muscle tone.
To clarify the clinical condition we can help us electrocardiogram, electromyography - to study nerve conduction, which shows a typical pattern, - the muscle biopsy, blood tests - which we highlight the creatine phosphokinase (CPK), an enzyme that is released into the circulation from the injured muscle -, the creatinine and the myoglobin, still being eventually to consider also a genetic study.
Due to be diseases for which there is currently no cure, their treatment is primarily supportive in order to prolong and improve the quality of life of the affected patients, so the orthopedist can just take action to compensate the consequences of the osteo-articular lesions.
Although they have common features, there are numerous presentations that form different defined clinical entities which often have the name of the first person that identifies or describes the disease.
The most common presentation of this group of diseases and one of the most severe is the Duchenne Muscular Dystrophy, linked to a chromosomal abnormality. The first symptoms appear relatively early, even in childhood, comprising frequent falls and difficulty of running or rise from the ground. There is a characteristic sign indicating the suspicion of the diagnosis, the Gowers sign, linked to the difficulty in raising after a fall. CPK is increased, existing often cardiomyopathy and pulmonary involvement. In terms of orthopedic pathology we can find contracture in flexion-abduction of the hip, contracture in flexion of the knee and the ankle or scoliosis.
The Becker progressive Muscular Dystrophy presents a clinical presentation similar to Duchenne Muscular Dystrophy, but appears later and the clinical presentation is less severe.
Steinert Muscular Dystrophy, or Steinert´s disease, is characterized by difficulty in muscle relaxation after contraction, often being associated with changes in other systems such as the vision, the skin, the skeleton, the endocrine system, the central and peripheral nervous system, the gastrointestinal system, or heart diseases.
The Fascioscapulohumeral Dystrophy mainly affects the muscles of the face and shoulder girdle, with the patient difficulty to closing eyes, ther mouth, or to smile or whistle.
The Limb-Girdle Muscular Dystrophy type mainly affects the muscles of the pelvic or shoulder girdle.
The Emery-Dreifuss Muscular Dystrophy is attributed to the anomaly of a muscle protein, emerin, manifesting clinically by muscular contractures of the limbs muscle atrophy and cardiac disorders.
The term Congenital Muscular Dystrophy encompasses a group of diseases characterized by weakness and decreased muscle tone, identifiable early during birth or during the first years of life, and classified according to the abnormality in question related to deficiency of specific proteins such as merosin, being these conditions related to genetic alterations.

Orthopedics and Vascular Diseases

A set of conditions that consists although essentially of Vascular Surgery pathologies must be considered as differential diagnosis in result of them produce a range of symptoms and signs which are partially overlapping to various orthopedic conditions.
Often patients presenting complaints such as pain, functional impotence, edema, inflammatory signs that primarily affect members are oriented towards the Orthopedics specialist, but their complains are based on very different pathology than initially supposed, deserving a brief mention.
Arteriosclerosis Obliterans is a disease characterized by occlusion of large and medium-sized arteries, especially in lower extremities due to extensive formation of atherosclerotic plaques, leading to peripheral ischaemia, i.e. the loss of blood flow by impaired circulation. When it reaches the lower limbs there is clinically with intermittent claudication, pain and muscle fatigue exacerbated by exercise, also as pallor and cooling of the extremities.
The Leriche Syndrome is a chronic occlusion located that at the level of the terminal part of the Aorta artery and the Iliac arteries that succeed it, leading to pain around the lower back, buttock, hips and thighs, usually from atherosclerotic origin, but may also be congenital.
Buerger's disease is a disorder characterized by recurrent episodes of inflammation and thrombosis of arteries of small and medium caliber, especially in the extremities of the limbs, which occurs predominantly in young male smokers. Symptoms can include pain, paresthesias of the extremities and cooling. Disease progression can condition the lack of irrigation, ischaemia, gangrene and can at a latter stage require amputation of the affected limb.
Raynaud's disease includes recurrent attacks of spasms, ie contractions, affecting peripheral arteries, especially arterioles, affecting essentially symmetrically the upper limbs of predominantly females, usually accentuated by the cold or by the emotions. The diagnosis is clinical and its character is benign. This differs from the Raynaud's phenomenon also known as Raynaud's syndrome, which generally arises when associated with another more severe disease, contrary to the Raynaud's disease.
The Chilblains results from an abnormal reaction to low temperatures, corresponding to ischemic for lack of circulation with destruction of superficial soft tissue as a result of exposure to cold.
Polyarteritis Nodosa is a progressive disease of inflammatory character with focal widespread commitment of the walls of medium and small caliber arteries, leading to the formation of nodules in these vessels. Its clinical manifestations are essentially secondary and vary according to the organ affected by the vasculitis, and its presentation may be made similar to joint complaints in Rheumatoid Arthritis, as well as associated muscle, skin, cardiac or renal disorders.
Within this group of diseases we can include Sudeck's Atrophy or Algodystrophy, which is a disease of unknown origin that arises as an unexpected complication in the evolution of the orthopedic treatment of certain lesions, characterized by severe atrophy of bone, with demineralization associated with pain, edema, hypersensitivity, cyanosis, cold, sweating, and stiffness, essentially reaching the hand, but can also occur in the foot, as well as in other segments of the upper or lower limbs. The mechanism that triggers it is unknown, existing an exaggerated response of the Sympathetic Nervous System, which is - along with the Parasympathetic Nervous System - one of the involuntary control mechanisms of the various organs of the human body, developing this disease in three phases, acute, dystrophic and atrophic.
The diagnosis is essentially clinical, so radiography just shows bone thinning due to demineralization. The scintigraphy and MRI can aid the diagnosis. Treatment is usually conservative and intended to promote the relief of symptoms.
Also within this disease group we must refer the Deep Venous Thrombosis, a complication often associated with orthopedic pathology, affecting most commonly the lower limb, either due to surgical aggression, either to prolonged immobilization, being, like the pulmonary thromboembolism, one of the most feared complications. It corresponds to the occlusion of lower limb veins caused by a thrombus or coagulum, causing pain, heaviness, swelling on the affected limb, and color changes - flushing, pallor or cyanosis (purple skin tone) - or local heat.
The diagnosis of deep vein thrombosis is complemented by medical exams, among which we point the ecodoppler, and its treatment includes anticoagulant drugs intended to leave the blood more fluid and the bed rest with elevation of the affected limb.
The unwanted release of the coagulum, or thrombus, can cause its migration through the blood stream to the brain, the lungs or the heart, causing serious injuries due to vascular obstruction.

Neurological pathology with reflex in Orthopedics

We refered previously Poliomyelitis and Cerebral Palsy as examples of neurological pathologies  affecting indirectly the locomotor system. However, there are plenty more pathologies in this context and I understand that some of them deserve special mention.
Some of the neurological lesions are due to anomalies during the formation of the spinal skeleton, even before the birth.
The Spina Bifida is a defect in the posterior arch of the affected vertebra, which may allow herniation, - output - of the neural structures that form the spinal cord, and may be associated with a congenital malformation of the early neurologic structures. The Spina Bifida can occur in a hidden way, being asymptomatic, without associated neurological damage, and being located more frequently in the fifth lumbar vertebra and the upper end of the Sacrum.
Closely related to the condition described above, but consisting of entirely separate entities, we can refer the Meningocele and the Myelomeningocele. When there is no neurological injury the pathology is probably a Meningocelo, which only reaches the meninges, a set of membranes that line and protect the whole central nervous system. The Myelomeningocele is a bag-like structure containing the cerebrospinal-fluid and the nervous tissue. The spinal cord and meninges are herniated - out of its usual location – and there is often associated with abnormalities such as bone marrow duplication - Diastematomyelia - hydrocephaly, or even severe skeletal abnormalities, such as the clubfoot, the neurologic dislocation of the hip or the scoliosis, usually progressive.
Another group of neurological disorders that undermines Orthopaedics are demyelinating diseases with inflammatory character reaching the central nervous system, as in the case of Multiple Sclerosis, or the peripheral nervous system, such as Guillain-Barre Syndrome, the Chronic Inflammatory Demyelinating Polyneuropathy or the Charcot-Marie-Tooth disease.
Multiple Sclerosis is a degenerative disease with a chronic autoimmune nature, affecting the elongated portion of the neurons, the axons, damaging the involving myelin sheath, causing it to demyelination of nerve, limiting the neuronal conduction. Clinically, patients may develop fatigue, lack of muscle strength in the limbs, changes in sensitivity, pain, changes in equilibrium, and abdominal or related to the vision complaints. The MRI and lumbar puncture help to diagnose the disease. Treatment is aimed at to controlling disease progression.
The Guillain-Barré syndrome is an inflammatory disease in which the immune system attacks the myelin sheath of the peripheral nerves and sometimes part of the brain. There is a severe decrease in muscle strength of the upper and lower limbs. The incidence increases with age and can occur after a viral infection such as the flu or the gastroenteritis, after a medical procedure, after pregnancy or with no apparent cause. Symptoms include progressive loss of muscle strength and paresthesias. There is no cure, but we can lessen the severity and speed the recovery.
The Charcot-Marie-Tooth disease is a hereditary neuropathy that affects the myelin sheath of the peripheral nerve axons. There is a symmetrical muscular atrophy slowly progressive and weakness in the limbs, especially the legs and the feet, with typical commitment of peroneal muscles, and often presenting deformities as cavus foot and claw toes.
The Chronic Inflammatory Demyelinating Polyneuropathy is a disease characterized by progressive muscle weakness, loss of reflexes and changes in sensitivity that is thought to be related to autoimmune processes attacking the myelin sheath of peripheral nerves, with a slow evolution, unlike the Guillain-Barré Syndrome.
Still inside of neurological diseases affecting the locomotor system can refer the Amyotrophic Lateral Sclerosis (ALS) and the Friedereich's Ataxia
In ALS there is a degeneration of motor neurons, which form a bridge between the brain and the muscles, leading to decreased innervation and consequent progressive muscular atrophy, involving both the spinal cord and the brain. It reaches the limbs, but also causes difficulty in breathing and swallowing. It does not reach the sensitivity, and rarely affecting the visceral organs or the intellectual capacity.
The Friedreich's Ataxia is an inherited disease affecting the central nervous system characterized by progressive degeneration of certain areas of the spinal cord. The main manifestations are orthopedic scoliosis and the cavus foot. Complaints include clumsy gait due to neuromuscular disorders, difficulty in speaking and changes in the sensitivity. The patient becomes bedridden relatively young, occurring cardiac abnormalities in a large percentage of cases.

Poliomyelitis and Cerebral Palsy

There are several neurological pathologies causing skeletal changes with relief in musculoskeletal system, requiring for its treatment medical or surgical acts of the Orthopedics specialty.
We will highlight two, Poliomyelitis and Cerebral Palsy, although to the first is actually rare to find clinical cases due to the efforts of vaccination campaigns with the aim of its eradication.
Poliomyelitis is an acute infectious disease caused by a highly contagious virus, the poliovirus, member of the family of the enteroviruses, with its spread and its mechanism of action due to the ingestion of products with fecal contamination, linked to poor hygiene conditions. The intestine infection spreads around all the body, reaching in a particularly severe way the central nervous system, imposing typical temporary or permanent destructive changes that can lead to paralysis and consequent deformities due to the achievement of the anterior horn motor neurons of the spinal cord or other brain motor nuclei.
The disease evolves in stages, beginning as an acute phase which starts the spread of the virus from the circulation, followed by an incubation period after an inflammatory condition similar to a cold, which can reach the central nervous system causing meningitis, that as the disease will progress and affect the neuronal cells may lead to a generalized paralysis, with consequent shortening of the muscles, which is followed by a convalescent phase, which may extend up to two years during which can occur some muscle recovery and finally a chronic stage that is established after two years past the initial presentation.
The orthopedic treatment during the acute phase aims to control the pain, the muscle spasm and make prophylaxis of the deformities. During the chronic phase, it may be considered tendons transfer, mainly in children, or bone corrections, usually after the growth. The purpose of the tendon transfers is to provide active motor strength to replace the function of the paralyzed muscle or eliminate the deforming action of the antagonist when the muscle is paralyzed, but also to promote the stability, improving muscular balance. The fusion of joints, or arthrodesis, aims to reduce the number of joints that paralyzed muscles must control.
Cerebral Palsy is he term that comprises a group of diseases affecting the central nervous system during its development, causing locomotion and posture alteration due to an injury in the immature brain, leading to a state of muscular dysfunction resulting from damage or disease of motor neurons higher than the level of the cerebral cortex or at the route of its fibers within the brain.
According to the members affected by paralysis it is classified as monoplegia if achieving only one member, hemiplegia when it reaches one side of the body, paraplegia when affecting the lower limbs, or quadriplegia or tetraplegia when it affects all the four. We may also refer to triplegia and diplegia when are affected both upper limbs.
Clinically it can have multiple presentations, being the Spastic Palsy by far the most common, characterized by increased muscle tone with exaggerated reaction to stretch, causing resistance that yields the insistence and accentuation of tendon reflexes. In addition to this, we still find the Athetoid/ Dyskinetic Palsy, characterized by irregular and uncontrollable involuntary movements and the Ataxic Palsy, that is  primarily related to the cerebellar lesions, causing lack of balance and coordination.
Cerebral palsy can occur in the prenatal period caused by infections such as rubella or toxoplasmosis, during the perinatal period, being the causes of brain injury at birth generally linked to the child-birth complications leading to anoxia, or lack oxygenation, or during the postnatal period, caused by encephalitis, seizures or head injury.
The child is late in sitting, standing stand, walking and talking. Deformities may include flexed elbow, flexed wrist, flexed fingers, thumbs adducted to palm,  hip flexed, adducted and internally rotated, flexed knees, equinus ankle and  flexed foot toes.
Treatment aims to compensate for muscle imbalance, trying to develop the weakened antagonistic muscles and stretch the spastic muscles.
Surgery is often indicated in patients with paralysis, including spastic, and may be useful to correct deformities, to balance muscle strength or stabilize joints.

Malignant Bone Tumors

We have been presented in a previous article some of the most important benign tumors, which, despite having different origin and presentations had in common the characteristic of staying locally limited, freeing up an invasive or expansive behavior.
However, there are tumors formed by atypical cells, which have the property of reproducing anarchically, invading adjacent tissues, causing disseminate them to distance, reflecting an invasive behavior that gradually affects vital functions and becomes in the medium term incompatible with the life of the organism, corresponding this pattern to the so-called malignant tumors, generally designated sarcomas.
In respect to malignant tumors that have as their starting point at the bone we shall outline the Osteosarcoma. It is the most common primary bone tumor, predominantly affecting children and adolescents, it is rare under the age of 10 and has a maximum peak incidence that coincides with the second decade of life, being located mainly in the metaphysis of the major long bones, essentially near the knee.
There are characteristic aspects in the radiography like the “sunburst” or “sun ray” aspect with the cortical bone destruction and the named Codman's triangle that appears at its end, presenting itself as an elevation of the cortical layer of the affected bone. Diagnostic confirmation and staging, ie the evaluation of the extent and severity of disease, requires the use of other medical examination tests such as the CT and the MRI. It is also essential to proceed to search distant metastases, particularly in the lungs, and at the time of initial diagnosis pulmonary microemboli already exist in most cases. As in almost all tumors, biopsy helps to confirm the diagnosis.
The treatment largely depends on the tumor stage, and its surgical recession is preferred. The radiation allows the destruction of tumor cells with minimal effect on the parts not affected, however it is not very effective for treating of this kind of tumor, so now the preferred treatment is the chemotherapy, which prevents the metastases in a large percentage of cases. Chemotherapy may be performed preoperatively to reduce the tumor mass and postoperatively, for further treatment.
The Chondrosarcoma is a malignant tumor arising from cartilage cells, and generally with better prognosis than the Osteosarcoma. Its most common localization is the shaft of long bones such as the femur and humerus, or the bones of the pelvic and shoulder girdle, as the pelvis and the scapula. The peak incidence is in the fourth to sixth decade of life. Because it is a derivative of cartilage tumor, its length is greater than that observed in the RX. Treatment usually consists in wide resection or amputation of the affected limb.
The Ewing's tumor has a controversial origin but it has apparently as starting point some embryonic primitive cells, being also associated with a translocation - a chromosomal change – and is more frequent in childhood and adolescence. Its location is predominantly the shaft of long bones and his prognosis is severe. Radiographically it usually has a characteristic pattern resembling the onion skin. The clinical presentation may be confused with osteomyelitis or bone infection, making thus important the differential diagnosis. It is a tumor sensitive to radiotherapy and chemotherapy.
The Multiple Myeloma is a tumor originated in blood cells located at the bone marrow, being derived from the proliferation of malignant plasma cells, usually occurring at older ages, about the sixth decade of life, predominantly affecting the pelvis, spine, skull and ribs. The plasmocyte is a differentiated cell in the production of antibodies and the proliferation of its malignant cells leading to a peak of a specific type of protein, known as Bence Jones protein, which is found in a large percentage of patients. The treatment is based on chemotherapy and radiotherapy, essentially as effort to control the disease in order to prevent its progression.
In addition to tumors whit primary origin in bone cells, they can also be caused by metastatic bone lesions, commonly originating from breast cancer carcinoma, kidney, lung, or prostate.
The complaints that guide us to the diagnosis include swelling, pain, or possibly fractures. For the diagnosis of the tumor can use the simple plain radiography, the blood tests, the bone biopsy, the CT and MRI. For the study of distant metastasis is important lung X-ray, abdominal ultrasound and also abdominal or thoracic CT.
As guideline we can consider that from around the fourth decade of life any bone tumor should initially be taken as metastasis, being mandatory outwit a possible primary tumor. Preferred locations of metastases are the spine, ribs, skull, femur and humerus.

Benign Bone Tumors

A tumor reflects an abnormal growth of cells within an organ. If this growth is contained and the cells do not have an invasive behavior, we will be facing a benign tumor. A malignant tumor has a proliferative and aggressive behavior, which may be limited in the initial stage by anatomical barriers and if is detected then it is possible its cure.
There is a multiplicity of bone tumors both benign and malignant, it is not easy each other differential diagnosis since its microscopic aspect has many similarities, which may make complex its classification.
Within an extensive list of bone tumors will point out the most relevant and those which appear most frequently in clinical practice. In general, those tumors derived of the bone are named osteomas and derivatives are termed cartilage tissue named chondroma,  adding to the malignant the suffix sarcoma.
I shall outline the osteochondroma, which is the largest group of benign bone tumors. It consists of spongy bone covered with cartilage there is a bursa which usually involves the tumor. Located predominantly at the distal end of the long bones, especially near the knee. Its removal is indicated if there is interference with joint function, fracture of symptomatic tumor or suspected malignancy.
The Enchondroma is a cartilaginous proliferation that develops within the bone itself, existing inland extensions of the fibrous capsule formation in, dividing the lobes, accompanied on RX by calcified dots. Usually does not require specific treatment, but only to advise its supervision. Due to weaken the bone is often the cause of fractures, which in many cases are the source of its diagnosis.
The Osteoid Osteoma is one of the presentations of osteomas, comprising vascularized fibrous tissue, fibroblast proliferation and tiny snippets of newly formed osteoid tissue. Its prevalence is in male and in the long bones, especially the tibia or the femur. Clinically there is prevalence of evening pain handing over to salicylates (aspirin). There is a central part, the nidus, which is the seat of the lesion and must be surgically removed to achieve the final treatment.
Giant Cell Tumor is an osteolytic tumor. It arises in the epiphysis after the closure of the epiphyseal plate where is the growth of cartilage. It is more common in the lower end of the femur, the distal end of the radius and the proximal end of the tibia, the joints usually are not being invaded. The pain, when there is present, usually worses at night and increases with activity. Radiologically there is multiple bone septa separating soft tissue islands that span the interior, giving it the appearance in soap bubbles. The tumor is composed of friable tissue, easily bleeding.
The Non-Ossify Fibroma is a well circumscribed fibrous neoformation within a small area that generally occurs in the metaphysis - that is, at the end - of a long bone, preferably the femur or tibia. Radiographically is an oval bone lesion located in its longitudinal axis.
The Aneurysmal Bone Cyst consists of a mass of vascular spaces contained in an ossified structure. Although it can occur in any bone, it mainly arises in the metaphyseal region of long bones, but also at spinal level. The affected bone is expanded, and cystic bulged out, with an irregular oval tumor mass.
As a last example of this group of tumors can refer Unicameral Bone Cyst, which corresponds to a thin-walled cavity that develops preferentially in the metaphysis of a long bone adjacent to the growth plate, being more frequent in the upper end of the humerus or femur, showing the bone fusiform structures expansion areas. A fracture by injury within the weakened bone is often the one to mak the diagnosis, which also may lead to the healing of the cyst in some cases.

Pediatric Orthopedic Pathology of the Knee, Foot and Spine

The knee is frequent headquarter of orthopedic disorders in children. Here also we find in early childhood pathologies overlapping the pediatric hip pathologies, such as congenital dislocation or septic arthritis, but being more are. In the same way, we also find diseases affecting the growth cartilage, as previously mentioned when was addressed the osteochondritis or osteochondrosis, so they will now be ignored.
One of the most frequent causes of medical consultations are the angular deformities of the knee in where the leg is presented arched inward with its ends are near and the knee joint is far, the varus knee, characteristic of the newborn and lasts for the first months, or sometimes arched in reverse sense, the valgus knee, most frequent from the 2 years old, giving the legs a similar look to an X. A varus knee with great deformity or one that persists after 2 years of age should be studied because it can be associated with congenital disorders such as Blount's disease and require specific treatment. As for the valgus knee, if it is quite pronounced it may eventually require surgery, which may be a temporarily hemiepifisiodese with  temporary growth arrest by blockage of one of the sides of the knee cartilage growth plate with devices such as staples and screws.
Another condition that affects quite often the adolescent knee is the patellofemoral instability, or Lateral Patellar Compresion Syndrome. The lower limb adult presents constitutionally with a slight valgus. Variation of normal anatomical relationships may favor an external deviation of the patella which tends to dislocate externally and be impacted of its joint surface with the femur. This condition can be treated in milder cases with muscle tightening, usually through of Physiotherapy, or require surgical correction involving both the muscle and tendon structures or bony structures, depending on its severity and the age at presentation.
Sometimes only the articular cartilage is affected, either through its weakening making it soft consistency giving rise to chondromalacia, or even causing injury forming a small island, the Osteochondritis Dissecans. The treatment varies depending on the way the lesion appears, which can be either surgical using perforations that aim of stimulating cartilage growth or replaced it by grafts comparable to small mosaics.
Another anatomical region may host orthopedic injuries in children is the foot, so it is important to outwit at birth a deformity affecting the posterior joints of the foot and ankle in which it presents in general terms with a strong internal rotation, specifically in flexion plant, adduction and inversion, Club Foot, or technically Congenital Talipes Equinovarus, which can be constitutional and require complex surgical treatments or just positional, treated conservatively. Its etiology is unknown, but there are several theories that attempt to explain its origin.
The plantar arch may appear decreased, giving the flatfoot or Pes Planus or accentuated, constituting the Cavus Foot. The foot of the child is plan bat irth, acquiring progressively the curvature of the plantar arch after the first year. His persistence may have pathological significance, although the deformity is usually not significant either originates no symptoms so it is rarely needed specific treatment, just the use of appropriate footwear for the age. The dimension of the deformity may require surgical treatment, and in the case of flatfoot is popular among us a technique known as "calcaneo-stop" where a screw serves as a stopper, correcting and preventing progression of the disease. The flatfoot can also be associated with various congenital or neurological conditions. The Cavus Foot is a complex deformity and is often associated with deformities of the fingers, such as claw finger and can be of constitutional origin but likely is associated with other pathologies than the flat foot.
Still at the foot level it may also rarely occur deformities like Syndactyly, which is the union of several fingers or through folds or more complex with bone fusions and polydactyly, which reflects the existence of accessory fingers, which can be real fingers or only incomplete projections.
With regard to the spine, the deformities that most affect children and adolescents are the Scoliosis and Kyphosis. The spine is observed from the front is usually a straight line and Scoliosis often reflects the existence of abnormal curvatures. Observed from profile, normal column shows anterior convexity curvature known as lordosis or posterior convexity, known as kyphosis, which may be at the dorsal level greatly exaggerated and have pathological significance. The age and the degree of deformity of these pathologies determine the treatment, ranging from the conservative, based on muscle tightening or postural correction in simple cases to surgical for the most severe deformities, but it is important to note that the deformity can progress following the growth, advising their supervision.
The Spondylolisthesis condition is also a spine pathology in which there is an abnormal slip of a vertebra over another, usually due to a loss of continuity of its posterior bony arch corresponding to Spondylolysis, being usually of congenital origin in children, allowing slip of the vertebral bodies, although it may eventually be traumatic.
Another condition of the spine that can occur in this age group is the Congenital Muscular Torticollis caused by a unilateral retraction of the sternocleidomastoid muscle. The severity of injury and response to therapy determines whether this is conservative or surgical.

Pediatric Orthopedic pathologies of the Hip

The hip is a joint where it can exist a set of important pathologies afeccting the development and maturation of the skeleton, with its common denominator, the claudication, vulgarly the limp. The frequency of the various orthopedic conditions affecting the hip that reach the younger segment of the population is distributed in a pattern associated with the age, so the most relevant causes of hip pathology according to the age group from birth to about two years are the Septic Arthritis and Congenital Dislocation of the Hip. After this age and up to about the four years, the hip complaints are usually due to Transient Synovitis. In the next age group up to about the ten years, as cause of hip pathology it should be primarily considered the Legg-Calvé-Perthes disease and after this age the Epiphysiolysis.
Septic Arthritis corresponds to the infection of a joint due to its invasion by different microbial agents, having deserved a specific approach in a text published previously.
The Congenital Dislocation of the Hip is a condition that must be screened in any newborn. The hip may be dislocated, or "undocked" with the head of the femur out of the acetabulum, or may be only dislocable. This pathology is screened at birth for a test known as Ortolani maneuver. Clinically we can view  asymmetrical gluteal creases or dysmetria, ie a difference in length between the two legs, and the diagnosis can be made by the ultrasound during the first months, once the femoral head is not ossified and is not visible to the radiography. The treatment is mainly conservative with own devices to immobilize and maintain the articulation stable but surgery may be needed in the cases wherereduction or maintenance is impossible in another way.
The Transient Synovitis is a benign inflammatory condition that affects multiple joints and the hips one of the most afected. It is a condition of unknown etiology causing pain and functional impotence with no apparent cause, or without analytical or imaging exam tranduction and that usually resolves in a few days by simply symptomatic treatment and rest.
The Legg-Perthes disease was also described before in another text were there are considered the osteochondrosis, a group of diseases that have in common to affect the vitality of the bone adjacent to the cartilage growth at its distal end, the epiphysis, in children.
The Epiphysiolysis is a pathology that affects the level below the epiphysis, the growth plate, causing a sliding of the more proximal portion of the femoral head relative to its metaphyseal basis. It may appear acutely, following a trauma or have a more insidious onset and take a chronic presentation. Its treatment is surgical, consisting in fixing the rotated fragment with wires or screws under radioscopic control.
Often the children are taken to the medical consultation due to appear to have their feet in internal rotation that is not related to foot pathology but with an anatomical change at the hip level. The region that joins the spherical head of the long bone portion, called the femoral neck, usually has a slight anterior deviation, causing that we call anteversion, which is more pronounced in the early years of life. An excessive increase of that anteversion favors the gait with the member in internal rotation, giving the feeling that the child has to excessively arched leg and foot is rotated inside. The evolution is usually benign and the treatment consists of surveillance and postural education.
Also within this group of conditions can include the coxa vara corresponding to a decrease in the angle of the femoral neck relative to the more elongated component, the shaft, which generally ranges between 120 and 140, making it more horizontal and thereby promoting indirectly shortening of the affected limb. A deformity in the opposite direction corresponds to coxa valga. More severe deformities may require surgical treatment.
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