JAAOS

JAAOS, Volume 11, No. 6


Ankle fractures resulting from rotational injuries.

Ankle fractures are among the most common skeletal injuries; selection of an optimal management method depends on ankle stability. Stable fractures (eg, isolated lateral malleolar) generally are managed nonsurgically; unstable fractures (eg, bimalleolar, bimalleolar equivalent) usually are managed with open reduction and internal fixation. Stress radiographs may aid in the management of incomplete deltoid injury in which there is medial swelling and tenderness without radiographic talar shift. A posterior malleolar fracture should be reduced and stabilized if it comprises >30% of the articular surface and remains displaced after fibular stabilization. Ankle fractures with syndesmotic injury have additional tibiofibular instability that can be controlled by screw fixation. However, the choice between metal and bioabsorbable screws, screw size, number of cortices fixed, and indications for screw removal remain controversial. Conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations.

    • Keywords:
    • Ankle Injuries|Arthroscopy|Biomechanics|Bone Screws|Fracture Fixation

    • Internal|Fractures

    • Bone|Humans|Rotation

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Articular cartilage biology.

Articular cartilage is a complex tissue maintained by chondrocytes, which undergo metabolic changes as a result of aging, disease, and injury. These changes may hinder tissue maintenance and repair, resulting in accelerated loss of articular surface and leading to end-stage arthritis. Researchers are investigating both normal and pathologic cellular and molecular processes as well as the development of chondroprotective agents to improve the metabolic function of articular cartilage. Current research is helping to clarify the mechanisms by which a variety of agents, such as glucosamine, chondroitin sulfate, hyaluronic acid, green tea, glucocorticoids, and nonsteroidal anti-inflammatory drugs, can modify the symptoms and course of osteoarthritis. Also under investigation are methods of stimulating repair or replacing damaged cartilage, such as matrix metalloproteinase inhibitors, gene therapy, growth factors, cytokine inhibitors, and artificial cartilage substitutes. Tissue engineering, the combining of artificial matrices with cells and growth factors or genes, offers great potential for improving patient care.

    • Keywords:
    • Cartilage

    • Articular|Humans|Osteoarthritis

    • Subspecialty:
    • Basic Science

Childhood diskitis.

Childhood diskitis may occur in the thoracic, lumbar, or sacral spine and can affect children of all ages, but it is most common in the lumbar region in children younger than 5 years. Physical examination, laboratory tests, and radiologic studies all aid in the diagnosis of this clinical syndrome, and proper use can prevent unnecessary invasive intervention. Presentation varies with age; the child may refuse to bear weight on the lower extremities or may present with back pain, abdominal pain, a limp, or, if an infant or toddler, with irritability. The etiology appears to be a bacterial infection, usually caused by Staphylococcus aureus. Most children improve rapidly with a 4- to 6-week course of antibiotics. Although not routinely necessary, immobilization decreases symptoms and, in the case of osseous destruction, prevents progression of spinal deformity. Biopsy of the infected disk space is reserved for children refractory to intravenous antibiotics. Follow-up should include plain radiographs at regular intervals for 12 to 18 months to ensure resolution of the destructive process.

    • Keywords:
    • Anti-Bacterial Agents|Child|Diagnosis

    • Differential|Diagnostic Imaging|Discitis|Humans|Staphylococcal Infections

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

Digital imaging and video: principles and applications.

Digital imaging has provided orthopaedic surgeons with new, powerful tools that offer a multitude of applications. Already integral to several common medical devices, digital images can be used for case documentation and presentation as well as for diagnostic and surgical patient care information. Educational presentation has been transformed by the use of computers and digital projectors. Understanding the basic foundations of digital imaging technology is important for effectively creating digital images, videos, and presentations.

    • Keywords:
    • Diagnostic Imaging|Humans|Image Processing

    • Computer-Assisted|Orthopedics|Radiographic Image Enhancement|Video Recording

    • Subspecialty:
    • Clinical Practice Improvement

Management of scaphoid nonunions.

Scaphoid nonunions result in a predictable pattern of wrist arthrosis. To minimize the incidence of arthrosis, the goal of treatment should be consolidation of the fracture with the scaphoid in anatomic alignment. Computed tomography and magnetic resonance imaging scans can aid evaluation of carpal collapse, scaphoid collapse, scaphoid nonunion, bone loss, and detection of osteonecrosis. Nonunion of the scaphoid waist may result in a humpback deformity, increasing the chances of further collapse and arthrosis. This collapse deformity must be approached volarly with an intercalary bone graft and internal fixation. A dorsal approach to proximal scaphoid nonunions allows easier access for removing the necrotic bone from the proximal pole and applying accurate screw or pin fixation. Vascularized bone graft is recommended to manage scaphoid nonunions with osteonecrosis.

    • Keywords:
    • Bone Transplantation|Diagnostic Imaging|Fracture Fixation

    • Internal|Fractures

    • Closed|Fractures

    • Ununited|Humans|Scaphoid Bone

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Nonsurgical management of idiopathic clubfoot.

Because nonsurgical management was thought not to yield adequate correction and a durable result, most children with idiopathic clubfoot have undergone surgery with extensive posteromedial and lateral release. However, surgical management caused residual deformity, stiffness, and pain in some children; thus, the favorable long-term results with the Ponseti and French methods of nonsurgical management have garnered interest. The Ponseti method consists of manipulation and casting of idiopathic clubfeet; the French method consists of physiotherapy, taping, and continuous passive motion. Careful evaluation of the techniques and results of these two approaches may increase their use and decrease or minimize the use of surgical management and thus the associated morbidity resulting from extensile releases.

    • Keywords:
    • Braces|Casts

    • Surgical|Clubfoot|Combined Modality Therapy|Humans|Infant|Infant

    • Newborn|Manipulation

    • Orthopedic

    • Subspecialty:
    • Foot and Ankle

    • Pediatric Orthopaedics

Soft-tissue injury associated with closed fractures: evaluation and management.

Determination of the severity of injury to the soft tissues is an important component of patient assessment and affects management of closed fractures. The response of soft tissue to blunt injury involves microvascular and inflammatory processes that produce localized tissue hypoxia and acidosis. Incisions placed through such compromised tissue can lead to wound breakdown and deep infection. Therefore, recognizing the signs of soft-tissue injury is the foundation for successful management of closed fractures. Many treatment options, including splinting, cryotherapy, compression, and delayed surgery, help limit further soft-tissue injury and facilitate its rapid recovery before surgical intervention. Emerging surgical techniques based on improved management have resulted in decreased rates of soft-tissue complications.

    • Keywords:
    • Fractures

    • Closed|Humans|Soft Tissue Injuries

    • Subspecialty:
    • Trauma

Sports and fitness activities: the negative consequences.

Participation in sports and fitness activities offers potential health benefits for individuals of all ages, such as combating obesity and osteoporosis, as well as enhancing cardiovascular fitness. Negative consequences of musculoskeletal injuries sustained during sports participation in childhood and adolescence may compromise function in later life, limiting the ability to experience pain-free mobility and engage in fitness-enhancing activity. Increasingly successful management of sports-related injuries has allowed more athletes to return to participation. However, even effective early management of meniscal or anterior cruciate ligament injury does not minimize or preclude the increased likelihood of developing subsequent osteoarthritis. In addition, even in the absence of injury, vigorous participation in sports and fitness activities during childhood and adolescence increases the likelihood of developing osteoarthritis. It is ironic that return to vigorous sports participation has been adopted as an important measure of success of treatment, yet few efforts have been made to document long-term consequences of continued participation. Awareness of the long-term consequences of intensive sport and fitness activities allows the physician to help patients make informed decisions about the types and levels of activity they choose.

    • Keywords:
    • Athletic Injuries|Cardiovascular Physiological Phenomena|Humans|Leg Injuries|Obesity|Physical Education and Training|Physical Fitness|Safety

    • Subspecialty:
    • Sports Medicine

    • Pediatric Orthopaedics

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