Apley's System of Orthopaedics and Fractures, 9th Edition

993 Pages·2010·59.43 MB·English

by  Louis Solomon, David Warwick, Selvadurai Nayagam

Apley’s
System of Orthopaedics
and Fractures

Alan Graham Apley 1914–1996
Inspired teacher, wise mentor and joyful friend

Louis Solomon MD FRCS
Emeritus Professor of Orthopaedics

Bristol
UK

David Warwick MD FRCS FRCSOrth Eur Dip Hand Surg
Consultant Hand Surgeon
Reader in Orthopaedic Surgery
University of Southampton
Southampton
UK

Selvadurai Nayagam BSc MChOrth
FRCSOrth
Consultant Orthopaedic Surgeon
Royal Liverpool Children’s Hospital
and
The Royal Liverpool University
Hospital
Liverpool
UK

Apley’s
System of Orthopaedics
and Fractures

Ninth Edition

iv

First published in Great Britain in 1959 by Butterworths Medical Publications
Second edition 1963
Third edition 1968
Fourth edition 1973
Fifth edition 1977
Sixth edition 1982
Seventh edition published in 1993 by Butterworth Heineman.
Eight edition published in 2001 by Arnold.
This ninth edition published in 2010 by
Hodder Arnold, an imprint of Hodder Education, an Hachette UK Company,
338 Euston Road, London NW1 3BH

http://www.hodderarnold.com

© 2010 Solomon, Warwick, Nayagam

All rights reserved. Apart from any use permitted under UK copyright law, this publica-
tion may only be reproduced, stored or transmitted, in any form, or by any means, with
prior permission in writing of the publishers or in the case of reprographic production, in
accordance with the terms of licences issued by the Copyright Licensing Agency. In the
United Kingdom such licences are issued by the Copyright Licensing Agency:
90 Tottenham Court Road, London W1T 4LP

Whilst the advice and information in this book are believed to be true and accurate at the
date of going to press, neither the author[s] nor the publisher can accept any legal
responsibility or liability for any errors or omissions that may be made. In particular (but
without limiting the generality of the preceding disclaimer) every effort has been made to
check drug dosages; however it is still possible that errors have been missed. Furthermore,
dosage schedules are constantly being revised and new side-effects recognized. For these
reasons the reader is strongly urged to consult the drug companies’ printed instructions
before administering any of the drugs recommended in this book.

British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication Data
A catalog record for this book is available from the Library of Congress

ISBN-13
978 0 340 942 055
ISBN-13 [ISE]
978 0 340 942 086 (International Students’ Edition, restricted
territorial availability)

1 2 3 4 5 6 7 8 9 10

Commissioning Editor:
Gavin Jamieson
Project Editor:
Francesca Naish
Production Controller:
Joanna Walker
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To our students, trainees and patients, all of whom have helped to make our lives
interesting, stimulating and worthwhile; and also to our wives and children (and
grand-children) who have tolerated our absences – both material and spiritual – while
preparing this new edition.

Dedication

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Contributors
ix
Preface
xi
Acknowledgements
xiii
List of abbreviations used
xv

PART 1:
GENERAL ORTHOPAEDICS

1 Diagnosis in orthopaedics
3
Louis Solomon, Charles Wakeley

2 Infection
29
Louis Solomon, H. Srinivasan, Surendar Tuli, Shunmugam Govender

3 Inflammatory rheumatic disorders
59
Christopher Edwards, Louis Solomon

4 Crystal deposition disorders
77
Louis Solomon

5 Osteoarthritis
85
Louis Solomon

6 Osteonecrosis and related disorders
103
Louis Solomon

7 Metabolic and endocrine disorders
117
Louis Solomon

8 Genetic disorders, skeletal dysplasias and malformations
151
Deborah Eastwood, Louis Solomon

9 Tumours
187
Will Aston, Timothy Briggs, Louis Solomon

10 Neuromuscular disorders
225
Deborah Eastwood, Thomas Staunton, Louis Solomon

11 Peripheral nerve injuries
269
David Warwick, H. Srinivasan, Louis Solomon

12 Orthopaedic operations
303
Selvadurai Nyagam, David Warwick

PART 2:
REGIONAL ORTHOPAEDICS

13 The shoulder and pectoral girdle
337
Andrew Cole, Paul Pavlou

14 The elbow and forearm
369
David Warwick

15 The wrist
383
David Warwick, Roderick Dunn

16 The hand
413
David Warwick, Roderick Dunn

17 The neck
439
Stephen Eisenstein, Louis Solomon

18 The back
453
Stephen Eisenstein, Surendar Tuli, Shunmugam Govender

Contents

19 The hip
493
Louis Solomon, Reinhold Ganz, Michael Leunig, Fergal Monsell,
Ian Learmonth

20 The knee
547
Louis Solomon, Theo Karachalios

21 The ankle and foot
587
Gavin Bowyer

PART 3:
FRACTURES AND JOINT INJURIES

22 The management of major injuries
627
David Sutton, Max Jonas

23 Principles of fractures
687
Selvadurai Nayagam

24 Injuries of the shoulder, upper arm and elbow
733
Andrew Cole, Paul Pavlou, David Warwick

25 Injuries of the forearm and wrist
767
David Warwick

26 Hand injuries
787
David Warwick

27 Injuries of the spine
805
Stephen Eistenstein, Wagih El Masry

28 Injuries of the pelvis
829
Louis Solomon

29 Injuries of the hip and femur
843
Selvadurai Nayagam

30 Injuries of the knee and leg
875
Selvadurai Nayagam

31 Injuries of the ankle and foot
907
Gavin Bowyer

Epilogue: Global Orthopaedics
935
Christopher Lavy, Felicity Briggs
Index
939

CONTENTS

viii

Principal Authors

Louis Solomon MD FRCS Eng FRCS Ed
Emeritus Professor of Orthopaedic Surgery

Honorary Consultant Orthopaedic Surgeon
Bristol Royal Infirmary, Bristol, UK

Selvadurai Nayagam BSc, MChOrth FRCSOrth
Consultant Orthopaedic Surgeon
Royal Liverpool Children’s Hospital and
The Royal Liverpool University Hospital
Liverpool, UK

David Warwick MD BM FRCS FRCS (Orth)
Eur Dip Hand Surg
Consultant Hand Surgeon
Reader in Orthopaedic Surgery
University of Southampton, Southampton, UK

Contributing Authors

Will Aston BSc, MBBS, FRCS Ed(TR&Orth)
Consultant Orthopaedic Surgeon
Royal National Orthopaedic Hospital
Stanmore, UK
Tumours

Gavin William Bowyer MA MChir FRCS(Orth)
Consultant Trauma and Orthopaedic Surgeon
and Honorary Senior Lecturer
Southampton University Hospitals
Southampton, UK
The Ankle and Foot
Injuries of the ankle and foot

Felicity Briggs MA(Oxon) UK
Research Assistant and Graduate Medical Student
Epilogue: Global Orthopaedics

Timothy William Roy Briggs MD(Res)
MCh(Orth) FRCS FRCS Ed
Professor and Consultant Orthopaedic Surgeon
Joint Medical Director
Joint Training Programme Director
Royal National Orthopaedic Hospital
Stanmore, UK
Tumours

Andrew Spencer Cole BSc MBBS
FRCS(TR&Orth)
Consultant Orthopaedic Surgeon
Southampton University Hospitals
Southampton, UK
The Shoulder and Pectoral Girdle
Injuries of the Shoulder and Upper Arm and elbow

Roderick Dunn MBBS DMCC FRCS(Plast)
Consultant Plastic, Reconstructive and Hand
Surgeon, Odstock Centre for Burns, Plastic and
Maxillofacial Surgery, Salisbury District Hospital
Salisbury, UK
The Wrist and The Hand: Congenital Variations

Deborah Eastwood FRCS
Consultant Orthopaedic Surgeon and
Hon Senior Lecturer
University College London;
Great Ormond Street Hospital for Children
London, UK
Genetic Disorders, Dysplasias and Malformations
Neuromuscular Disorders

Christopher J Edwards BSc MBBS FRCP MD
Consultant Rheumatologist & Honorary Senior
Lecturer
Associate Director
Wellcome Trust Clinical Research Facility
Southampton University Hospitals NHS Trust
Southampton General Hospital, UK
Inflammatory Rheumatic Disorders

Contributors

Stephen Eisenstein PhD FRCS(Ed)
Hon Professor, Keele University; Emeritus Director
Centre for Spinal Studies;
The Robert Jones and Agnes Hunt Orthopaedic
Hospital, Shropshire, UK
The Neck
The Back
Injuries of the Spine

Reinhold Ganz MD
Professor and Chairman Emeritus
Orthopaedic Department Inselspital
University of Bern, Switzerland
The Hip: Femoro-acetabular Impingement

Shunmugam Govender MBBS MD FRCS
FC(Orth) (SA)
Professor and Head of Department of Orthopaedics;
Director of Spinal Services King George V Hospital;
Nelson R Mandela School of Medicine
Durban, South Africa
Infection
The Back: Infections of the Spine

Max Jonas MBBS FRCA
Consultant and Senior Lecturer in Critical Care
Southampton University Hospitals NHS Trust
Southampton, UK
The Management of Major Injuries

Theo Karachalios MD DSc
Associate Professor in Orthopaedics,
School of Health Sciences, University of Thessalia
University General Hospital of Larissa
Hellenic Republic
The Knee

Christopher Lavy OBE MD MCh FRCS
Hon Professor and Consultant,
Nuffield Department of Orthopaedic Surgery,
University of Oxford, UK
Epilogue: Global Orthopaedics

Ian Douglas Learmonth MB ChB FRCS Ed FRCS
FCS(SA)Orth
Emeritus Professor, ;
Honorary Consultant, University Hospitals, Bristol;
Honorary Consultant, North Bristol Trust, UK
Total Hip Replacement

Michael Leunig MD
Head of Orthopaedics, Lower Extremities
Schulthess Klinik, Zurich, Switzerland
The Hip: Femoro-Acetabular Impingement

Wagih S El Masry FRCS FRCP
Consultant Surgeon in Spinal Injuries;
Director, Midlands Centre for Spinal Injuries
President International Spinal Cord Society (ISCOS)
RJ & AH Orthopaedic Hospital, Oswestry, UK
Injuries of the Spine

Fergal P Monsell MSc FRCS FRCS(Orth)
Consultant Paediatric Orthopaedic Surgeon
Bristol Royal Hospital for Children
Bristol, UK
The Hip: Disorders in Children

Paul Pavlou BSc (Hons) MB BS MRCS
Orthopaedic Registrar, Wessex training scheme
The Shoulder and Pectoral Girdle
Injuries of the Shoulder

H. Srinivasan MB BS FRCS FRCS Ed
DSc (Hon)
Formerly Senior Orthopaedic Surgeon
Central Leprosy Teaching & Research Institute
Chengalpattu (Tamil Nadu), India;
Director Central JALMA Institute for Leprosy
(ICMR), Agra (UP), India; and Editor Indian
Journal of Leprosy
Infection and Peripheral Nerve Disorders: Leprosy

Thomas G Staunton MB FRCP(C) FRCP
Consultant Neurologist
Norfolk and Norwich University Hospital;
Consultant Clinical Neurophysiologist
Robert Jones and Agnes Hunt Orthopaedic
Hospital, Shropshire, UK
Neuromuscular Disorders: Neurophysiological Studies

David Sutton BM DA FRCA
Department of Anaesthetics
Southampton General Hospital
Southampton, UK
Management of Major Injuries

Surendar Mohan Tuli MBBS MS PhD
Senior Consultant in Spinal Diseases and
Orthopaedics, Vimhans Hospital, New Delhi, India
Infection: Tuberculosis of Bones and Joints
The Back

Charles J Wakeley BSc MBBS FRCS FRCS Ed
FRCR
Consultant Radiologist, Department of Radiology
University Hospital Bristol NHS Foundation Trust
Bristol, UK
Diagnosis in Orthopaedics: Imaging

CONTRIBUTORS

x

When Alan Apley produced the first edition of his Sys-
tem of Orthopaedics and Fractures 50 years ago he
saw it as an aid to accompany the courses that he con-
ducted for aspiring surgeons who were preparing for
the FRCS exams. With characteristic humour, he
called the book ‘a prophylactic against writer’s
cramp’. Pictures were unnecessary: if you had any
sense (and were quick enough to get on the heavily
oversubscribed Apley Course) you would be treated
to an unforgettable display of clinical signs by one of
the most gifted of teachers.
You also learnt how to elicit those signs by using a
methodical clinical approach – the Apley System. The
Fellowship exam was heavily weighted towards clinical
skills. Miss an important sign or stumble over how to
examine a knee or a finger and you could fail outright.
What Apley taught you was how to order the steps in
physical examination in a way that could be applied to
every part of the musculoskeletal system. ‘Look, Feel,
Move’ was the mantra. He liked to say that he had a
preference for four-letter words. And always in that
order! Deviate from the System by grasping a
patient’s leg before you look at it minutely, or by test-
ing the movements in a joint before you feel its con-
tours and establish the exact site of tenderness and
you risked becoming an unwilling participant in a the-
atrical comedy.
Much has changed since then. With each new edi-
tion the System has been expanded to accommodate
new tests and physical manoeuvres developed in the
tide of super-specialisation. Laboratory investigations
have become more important and imaging techniques
have advanced out of all recognition. Clinical classifi-
cations have sprung up and attempts are now made to
find a numerical slot for every imaginable fracture. No
medical textbook is complete without its ‘basic sci-
ence’ component, and advances are so rapid that
changes become necessary within the period of writ-
ing a single edition. The present volume is no excep-
tion: new bits were still being added right up to the
time of proof-reading.
For all that, we have retained the familiar structure
of the Apley System. As in earlier editions, the book is
divided into three sections: General Orthopaedics,

covering the main types of musculoskeletal disorder;
Regional Orthopaedics, where we engage with these
disorders in specific parts of the body; and thirdly
Fractures and Joint Injuries. In a major departure
from previous editions, we have enlisted the help of
colleagues who have particular experience of condi-
tions with which we as principal authors are less famil-
iar. Their contributions are gratefully acknowledged.
Even here, though, we have sought their permission
to ‘edit’ their material into the Apley mould so that
the book still has the sound and ‘feel’ of a single
authorial voice.
For the second edition of the book, in 1963, Apley
added a new chapter: ‘The Management of Major
Accidents’. Typically frank, he described the current
arrangements for dealing with serious accidents as
“woefully inadequate” and offered suggestions based
on the government’s Interim Report on Accident
Services in Great Britain and Ireland (1961). There
has been a vast improvement since then and the num-
ber of road accident deaths today is half of what it was
in the 1960’s (Department of Transport statistics). So
important is this subject that the relevant section has
now been re-written by two highly experienced Emer-
gency and Intensive Care Physicians and is by far the
longest chapter in the present edition.
Elsewhere the text has been brought completely up
to date and new pictures have been added. In most
cases the illustrations appear as composites – a series
of images that tell a story rather than a single ‘typical’
picture at one moment in the development of some
disorder. At the beginning of each Regional chapter,
in a run of pictures we show the method of examin-
ing that region: where to stand, how to confront the
patient and where to place our hands. For the experi-
enced reader this may seem like old hat; but then we
have designed this book for orthopaedic surgeons of
all ages and all levels of experience. We all have some-
thing to learn from each other.
As before, operations are described only in outline,
emphasising the principles that govern the choice of
treatment, the indications for surgery, the design of the
operation, its known complications and the likely out-
come. Technical procedures are learnt in simulation

Preface

courses and, ultimately, in the operating theatre. Writ-
ten instructions can only ever be a guide. Drawings are
usually too idealised and ‘in theatre’ photographs are
usually intelligible only to someone who has already
performed that operation. Textbooks that grapple with
these impediments tend to run to several volumes.
The
emphasis
throughout
is
on
clinical
orthopaedics. We acknowledge the value of a more
academic approach that starts with embryology,
anatomy, biomechanics, molecular biology, physiol-
ogy and pathology before introducing any patient to
the reader. Instead we have chosen to present these
‘basic’ subjects in small portions where they are rele-
vant to the clinical disorder under discussion: bone
growth and metabolism in the chapter on metabolic
bone disease, genetics in the chapter on osteodystro-
phies, and so forth.
In the preface to the last edition we admitted our
doubts about the value of exhaustive lists of references
at the end of each chapter. We are even more divided

about this now, what with the plethora of ‘search
engines’ that have come to dominate the internet. We
can merely bow our heads and say we still have those
doubts and have given references only where it seems
appropriate to acknowledge where an old idea started
or where something new is being said that might at
first sight be questioned.
More than ever we are aware that there is a dwin-
dling number of orthopaedic surgeons who grew up
in the Apley era, even fewer who experienced his
thrilling teaching displays, and fewer still who worked
with him. Wherever they are, we trust that they will
recognise the Apley flavour in this new edition. Our
chief concern, however, is for the new readers who –
we hope – will glean something that helps them
become the next generation of teachers and mentors.

LS
SN
DJW

PREFACE

xii

Fifty years ago Apleys’ System of Orthopaedics and
Fractures was written by one person – the eponymous
Apley. As the years passed and new editions became
ever larger, a second author appeared and then a
third. Throughout those years we have always been
able to get help (and sometimes useful criticism) from
willing colleagues who have filled the gaps in our
knowledge. Their words and hints are scattered
among the pages of this book and we are forever
grateful to them.
For the present edition we have gone a step further
and enlisted a number of those colleagues as nomi-
nated Contributing Authors. In some cases they have
brought up to date existing chapters; in others they
have added entirely new sections to a book that has
now grown beyond the scope of two or three special-
ists. Their names are appropriately listed elsewhere
but here we wish to thank them again for joining us.
They have allowed us to mould their words into the
style of the Apley System so that the text continues to
carry the flavour of a unified authorial voice.
We are also grateful to those colleagues who have
supplied new pictures where our own collections have
fallen short. In particular we want to thank Dr
Santosh Rath and Dr G.N. Malaviya for pictures of
peripheral deformities in leprosy, Mr Evert Smith for
pictures (and helpful descriptions) of modern
implants in hip replacement operations, Dr Peter Bul-
lough who allowed us to reprint two of the excellent
illustrations in his book on Orthopaedic Pathology,
and Dr Asif Saifuddin for permission to use some
images from his book on Musculoskeletal MRI.
Others who gave us generous assistance with pictures

are Fiona Daglish, Colin Duncan, Neeraj Garg,
Nikolaos Giotakis, Jagdeep Nanchahal and Badri
Narayan.
We have been fortunate in having friends and family
around us who have given us helpful criticism on the
presentation of this work. Caryn Solomon, a tireless
internet traveller, found the picture for the cover and
Joan Solomon gave expert advice on layout and
design. James Crabtree stepped in as a model for
some ‘clinical’ pictures. We are grateful to all of them.
Throughout the long march to completion of this
work we have enjoyed the constant help and collabo-
ration of Francesca Naish, Gavin Jamieson, Joanna
Walker and Helen Townson (our Editorial Manager,
Commissioning Editor, Production Manager and
Design Manager respectively) at Hodder Arnold. No
problem was too complex and no obstacle too great
to withstand their tireless efforts in driving this work
forward.
Nora Naughton and Aileen Castell (Naughton
Project Management) were in the background setting
up the page copies, patiently enduring the many
amendments that came in over the internet. Their
attention to detail has been outstanding.
Finally, we want to express our deepest thanks to
those nearest to us who added not a word to the text
but through their support and patience made it poss -
ible for us to take so much time beyond the everyday
occupations of family life to produce a single book.

L. S.
D.W.
S. N.

Acknowledgements

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