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Case Study 19-1: Arthroplasty of the Right TMJ

S.A., a 38-year-old teacher, was admitted for surgery for degenerative joint disease (DJD) of her right temporomandibular joint (TMJ). She has experienced chronic pain in her right jaw, neck, and ear since her automobile accident the previous year. S.A.'s diagnosis was confirmed by CT scan and was followed up with conservative therapy, which included a bite plate, NSAIDs, and steroid injections. She had also tried hypnosis in an attempt to manage her pain but was not able to gain relief. Her doctor referred her to an oral surgeon who specializes in TMJ disorders. S.A. was scheduled for an arthroplasty of the right TMJ to remove diseased bone on the articular surface of the right mandibular condyle.

On the following day, she was transported to the OR for surgery. She was given general endotracheal anesthesia, and a vertical incision was made from the superior aspect of the right ear down to the base of the attachment of the right earlobe. After appropriate dissection and retraction, the posterior-superior aspect of the right zygomatic arch was bluntly dissected anteroposteriorly. With a nerve stimulator, the zy-gomatic branch of the facial nerve was identified and retracted from the surgical field with a vessel loop. The periosteum was then incised along the superior aspect of the arch. An inferior dissection was then made along the capsular ligament and retracted posteriorly. With a Freer elevator, the meniscus was freed, and a horizontal incision was made to the condyle. With a Hall drill and saline coolant, a high condylec-tomy of approximately 3 mm of bone was removed while conserving function of the external pterygoid muscle. The stump of the condyle was filed smooth and irrigated copiously with NSS. The lateral capsule, periosteum, subcutaneous tissue, and skin were then closed with sutures. The facial nerve was tested before closing and confirmed to be intact. A pressure pack and Barton bandage were applied. The sponge, needle, and instrument counts were correct. Estimated blood loss (EBL) was approximately 50 mL.

S.A. was discharged on the second postoperative day with instructions for soft diet; daily mouth opening exercises; an antibiotic (Keflex 500 mg po q6h); Tylenol no. 3 po q4h prn for pain; and four weekly postoperative appointments.

Case Study 19-2: Osteogenesis Imperfecta

M.H., a 3-year-old boy with osteogenesis imperfecta (OI) type III, was admitted to the pediatric orthopedic hospital for treatment of yet another fracture. Since he was born he has had 15 fractures of his arms and legs. His congenital disease is manifested by a defect in the creation of bone matrix, which gives normal bone its strength. His bones are very brittle and break with little pressure or trauma. This latest fracture occurred when he twisted at the hip while standing in his wheeled walker. He has been in a research study and receives a bisphosphonates infusion every 2 months. He is short in stature with short limbs for his age, and has bowing of both legs. He also has a pectus cavernosus of his chest, an inversion or concavity of the sternum.

M.H. was transferred to the OR and carefully lifted to the OR table by the staff. After he was anesthetized, he was positioned with gentle manipulation, and his left hip was elevated on a small gel pillow. After skin preparation and sterile draping, a stainless steel rod was inserted into the medullary canal of his left femur to reduce and stabilize the femoral fracture. The muscle, fascia, subcutaneous tissue, and skin were sutured closed. Three nurses gently held M.H. in position on a pediatric spica box while the surgeon applied a hip spica (body cast) to stabilize the fixation, protect the leg, and maintain abduction. M.H. was transferred to the PACU for recovery. The surgeon dictated the procedure as an open reduction internal fixation (ORIF) of the left femur with intramedullary rodding (IM) and application of spica cast.

Case Studies, continued

Case Study 19-3: Idiopathic Adolescent Scoliosis

Four years ago, L.R., who is now 15, had a posterior spinal fusion (PSF) for correction of idiopathic adolescent scoliosis in a pediatric orthopedic hospital in another state. Her spinal curvature had been surgically corrected with the insertion of bilateral laminar and pedicle hooks and two 3/16-inch rods. A bone autograft was taken from her right posterior superior ilium and applied along the lateral processes of T4 to L2 to complete the fusion.

During a follow-up visit, she presented with a significant prominence of the right scapula and back pain in the mid and lower back. She denied numbness or tingling of the lower extremities, bowel or bladder problems, chest pain, and shortness of breath. A CT scan of the upper thoracic spine showed a prominent rotatory scoliosis deformity of the right posterior thorax with acute angulation of the ribs. Her deformity is a common consequence of overcorrection of prior spinal fusion surgery, called crank shaft phenomenon.

L.R. was referred to the chief spinal surgeon of a local pediatric orthopedic hospital for removal of the spinal instrumentation, posterior spinal osteotomies from T4 to L2, insertion of replacement hooks and rods, bilateral rib resections, autograft bone from the resected ribs, partial scapulectomy, and possible allograft bone and bilateral chest tube placement. The surgical plan was explained to her and her mother and consent was obtained and signed. The surgical procedure as well as the potential benefits versus risks were discussed. L.R. and her mother stated that they fully understood and provided consent to proceed with the plan for surgery.

CASE STUDY QUESTIONS

Multiple choice: Select the best answer and write the letter of your choice to the left of each number.

a. removal of a joint capsule b. plastic repair of a vertebra c. removal of a rounded bone protuberance d. enlargement of a cavity e. removal of a tumor

_ 2. The articulating surface of a bone is located:

a. under the epiphysis b. in a joint c. around the bone marrow d. at a muscle attachment e. at a tendon attachment

_ 3. The dissection of the zygomatic arch was directed anteroposteriorly, which describes:

a. posterior-superior b. circumferential c. front to back d. top to bottom e. perpendicular to the mandible

Case Studies, continued

4. Another term for bow-legged is:

a. internal rotation b. knock-kneed c. adduction d. varus e. valgus

a. inferior to the femoral condyle b. into the acetabulum c. within the medullary canal d. on top of the periosteum e. lateral to the epiphyseal growth plates

6. The anatomic area described as thoracic or the thorax is the:

a. chest b. lower pelvis c. between sternum and umbilicus d. shoulders e. posterior abdomen

7. L.R.'s spinal fusion will immobilize the spinal levels of T4 to L2. These segments describe the_and_vertebrae.

a. cervical and lumbar b. sacral and cranial c. lamina and disks d. thoracic and lumbar e. lumbar and thoracic

8. The grafted bone for L.R.'s fusion came from her own right ilium. The proper name for this

is

a(n):

a.

allograft

b.

autograft

c.

heterograft

d.

iliograft

e.

homograft

Write a term from the case studies with each of the following meanings:

9. pertaining to the cheekbone _

10. the membrane around the bone _

11. a crescent-shaped cartilage in a joint _

13. breastbone

Case Studies, continued

14. plastic repair of a joint

15. term for a disease of unknown origin

16. removal of the shoulder blade

17. a break in the integrity of a bone

18. surgical openings into bones Abbreviations. Define the following abbreviations:

19.

DJD _

20.

MRI

21.

NSAIDs

22.

CT

23.

NSS

24.

TMJ _

25.

OI

26.

ORIF

27.

PSF

28.

EBL

Chapter 19 Crossword The Skeleton

Skeleton Crossword

ACROSS

DOWN

5.

Study and treatment of the skeleton, muscles, and

1.

Pertaining to the cranium and sacrum

associated structures

2.

Last portion of the spinal column: abbreviation

9.

Abbreviation used in taking medical histories

3.

Pain: suffix

10.

Deficiency of: suffix

4.

Same, equal: prefix

12.

Instrument for measuring joint angles:

6.

A bone disease is named for him

meter

7.

Cartilage: combining form

13.

New: prefix

8.

Vertebra: combining form

14.

Cold: root

11.

Immobility of a joint

15.

First cervical vertebra

16.

Stones: suffix

17.

Twice per day: abbreviation

17.

Blood pressure: abbreviation

20.

Breakdown and removal of bone

18.

Two, twice: prefix

21.

Type of arthritis: abbreviation

19.

Meaning of the prefix tel/o

22.

Slipping of a vertebra:

CHAPTER

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