This text is intended for primary-care providers and nursing personnel, who usually are the first individuals to evaluate orthopaedic problems. The goal of the text—to help these health-care professionals evaluate basic problems and make referrals to orthopaedic surgeons when appropriate—is largely fulfilled. However, this task is ambitious and, as a consequence, some sections of the text are confusing; it is not always clear what the primary-care provider should do or when the referral should be made, despite the fact that the authors have tried to provide so-called red flags for referral.
The book's strengths deserve mention. Most of the diagrams, photographs, and tables are superb. The glossary of orthopaedic terms unravels some of our inbred verbiage for our colleagues. The broad yet comprehensive section on bone tumors is an excellent resource. The tables, such as the one on non-steroidal anti-inflammatory medications, are very convenient reference sources that are not easy to come by elsewhere. The section on splinting, with an appropriate table of materials and photographs, is excellent. The section on physical examination and treatment of the shoulder is good, as are the sections on the foot, ankle, and spine. The system of indexing and the uniformity of the text make it easy for the primary-care provider to locate a disorder alphabetically while evaluating the patient.
Other portions of the text are less satisfactory. The section on the principles of treatment of fractures includes only three sentences of instruction on how to perform a reduction of a displaced fracture. The inclusion of such information assumes that the primary-care provider would try to perform such a reduction. The section on the elbow describes the oral use of steroids for a week, with increasing doses for inflammatory problems. Elsewhere in the text, the injection of steroids into joints and around fascial inflammatory areas is suggested. The illustration showing an injection into the carpal tunnel implies that this might be an appropriate approach for the primary-care provider to attempt before an orthopaedist is consulted. The section on the hand has many problems. For example, diagrams demonstrating incision and drainage of an infected fingertip suggest that this procedure should be done by the primary-care physician. It also is suggested that a fracture of the scaphoid should be treated by the primary-care provider initially and should be seen by the orthopaedist only if it has not united after months of immobilization. A number of diagrams show aspiration of ganglions, including those of the volar aspect of the radius. The reader is advised that such a ganglion may be near the radial artery but is not cautioned that aspiration may cause serious problems.
The section on pediatric orthopaedics is well written but may be confusing because of its brevity. The section on fractures of both bones of the forearm suggests that fractures with more than 15 degrees of angulation should be referred to an orthopaedist. This implies that other such fractures with less angulation can be treated by the primary-care provider. However, the decision to treat should be based on the age of the child, the location of the angulation with respect to the axes of the wrist and elbow joints, and the method used to measure the angulation. In an earlier section of the book, torus fractures in younger children are described as being treated with a below-the-elbow splint or cast rather than with traditional above-the-elbow immobilization. The section on fractures involving the supracondylar area of the elbow in children cites a complication that is referred to as "compartment syndrome with Volkmann's contracture." This complication also is mentioned in the section of the text dealing with acute compartment syndrome. However, the pairing of these two conditions is confusing. Although the authors realize that these two entities are not identical, it is difficult to decipher the relationship between them in the short sections in which they are discussed. The text also suggests that non-displaced supracondylar fractures can be treated by the primary-care physician. This discussion includes the recommendation that the patient and family should be advised of possible complications and should contact the primary-care physician if any of these problems occur; the need for the physician to see the child within the first twenty-four hours after treatment of such a fracture is not emphasized. Again, such a fracture would best be treated initially, and followed, by an experienced orthopaedic surgeon who can judge whether or not the fracture is displaced and can deal with the myriad sequelae. The section on Legg-Perthes disease implies that there is no reason to refer the patient to an orthopaedic surgeon because operative treatment rarely is indicated and because bracing is indicated only for older children. The authors should have stated that most of these children should be referred because subluxation of the hip may develop, thereby necessitating operative treatment. The section on slipped capital femoral epiphysis does not distinguish acute (unstable) slips from chronic ones; however, this may not be very important because the reader is advised that all of these patients should be referred.
This book will be most useful for a primary-care provider who is in an isolated position—for example, an independent primary-care practitioner in the armed forces or, perhaps, a practitioner in a rural setting. In such situations, no orthopaedic surgeon would be available and these suggestions for treatment might then be appropriate. This text will also be appropriate for the education of physicians and nurses who initially evaluate patients in the urgent-care setting. Its greatest weakness is that it does not consistently give the reader who practices in a location where consultants are available a sense of which disorders should be treated and which should be referred. This is an important issue for most primary-care providers, and it should be dealt with in a second edition.
M. Mark Hoffer, M.D.
Downey, California