Osteoarthritis

The term osteoarthritis is a misnomer, because inflammation is not the primary pathologic process observed in this form of articular joint disruption.

More accurately described as degenerative joint disease, the disease represents a final common pathway of injury to articular cartilage. Although the true nature and cause of osteoarthritis are unclear, radiographic findings and gross and microscopic pathologic features are fairly typical in most cases.

Epicondylitis

Medial (‘golfer’s elbow’) and lateral (‘tennis elbow’) Epicondylitis are in fact misnomers as inflammation is secondary to the primary pathology, tendon degeneration.

The common flexor origin and the extensor carpi radialis brevis are the respective culprits. Anti-inflammatories, oral and locally injected, are usually ineffective and attention should focus on correcting playing style, grip size (tennis racquet) and equipment (light, graphite racquet) before reducing the frequency of playing. Local physical therapies are beneficial but if these measures fail, the degenerate area is excised and the tendon repaired.

Neurogenic Shock

High spinal cord injuries can also result in systemic hypotension because of loss of sympathetic tone. The patient will usually have hypotension and relative bradycardia and will show evidence of good peripheral perfusion on physical examination. The term neurogenic shock is used but is somewhat of a misnomer because these patients are typically hyperdynamic, with high cardiac output secondary to loss of sympathetic vascular tone.

After hemorrhagic causes of hypotension have been ruled out, the hypotension associated with high spinal injury can be treated by the administration of an a-agonist such as phenylephrine.

Slipped Capital Femoral Epiphysis

A slipped capital femoral epiphysis (SCFE) is a developmental disorder in which there is dissociation between the epiphysis and metaphysis of the proximal femur. The term is a misnomer because the epiphysis is fixed in the acetabulum and it is the metaphysis, along with the rest of the femur, that slips.

In the vast majority of slips, the epiphysis is posteromedial with respect to the metaphysis. A SCFE usually occurs during the adolescent growth spurt and is bilateral in about one-third of cases. Sixty to 65% of patients are above the 90th percentile for weight.


Patients usually present with pain and a limp. The extremity is usually rotated externally and the time spent on the leg is less than the unaffected leg. The gait produced from this shortened time on the leg is called an antalgic gait and is an indication of pain with weight bearing. The pain is frequently in the thigh or knee despite the pathology being at the hip. The physical exam is most remarkable for limitation of internal rotation of the hip. Radiographs are usually diagnostic and are used to grade the severity of the slip. Occasionally, an MRI is needed to visualize a very early SCFE or "preslip." SCFEs are classified as acute if symptoms have been present for less than 3 weeks, and chronic or acute-on-chronic if there has been a recent exacerbation. They are also classified as stable or unstable depending on whether the patient can bear weight. Acute, unstable slips require emergent treatment.


The treatment of virtually all SCFEs is to stabilize the slip with one partially-threaded, cannulated screw. Reducing the slippage is contraindicated because it damages the blood supply to the epiphysis and may cause osteonecrosis of the femoral head. Occasionally, a reconstructive osteotomy is required to improve the mechanics of the joint.