JAAOS

JAAOS, Volume 15, No. 4


Acute midshaft clavicular fracture.

Clavicular fractures represent 2.6% to 5% of all fractures, and middle third fractures account for 69% to 82% of fractures of the clavicle. The junction of the outer and middle third is the thinnest part of the bone and is the only area not protected by or reinforced with muscle and ligamentous attachments. These anatomic features make it prone to fracture, particularly with a fall on the point of the shoulder, which results in an axial load to the clavicle. Optimal treatment of nondisplaced or minimally displaced midshaft fracture is with a sling or figure-of-8 dressing; the nonunion rate is very low. However, when midshaft clavicular fractures are completely displaced or comminuted, and when they occur in elderly patients or females, the risk of nonunion, cosmetic deformity, and poor outcome may be markedly higher. Thus, some surgeons propose surgical stabilization of a complex midshaft clavicular fracture with either plate-and-screw fixation or intramedullary devices. Further randomized, prospective trials are needed to provide better data on which to base treatment decisions.

    • Keywords:
    • Clavicle|Fracture Fixation

    • Internal|Fractures

    • Bone|Humans|Internal Fixators|Trauma Severity Indices|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

Interspinous process spacers.

The patient with neurogenic claudication resulting from lumbar spinal stenosis who fails to experience satisfactory relief from nonsurgical measures has limited treatment options. Lumbar epidural steroid injections and surgical laminectomy are generally accepted alternatives for the patient with moderate to severe symptoms. Interspinous process spacers, a relatively new class of technology, are proposed for use in the patient who prefers less invasive surgery or in whom medical comorbidities preclude a major surgical procedure. Early data from biomechanical and clinical studies support the short-term efficacy of interspinous process spacers in treating claudication related to spinal stenosis. Sufficient medium- and long-term data are lacking, however, particularly with respect to durability of symptomatic relief and the risk of device migration or dislocation. Although interspinous process spacers are a promising new technology, the results of longer-term clinical follow-up studies are needed to more clearly define their role in the management of lumbar spinal stenosis.

    • Keywords:
    • Humans|Low Back Pain|Lumbar Vertebrae|Orthopedic Procedures|Prosthesis Design|Prosthesis Implantation|Spinal Stenosis|Treatment Outcome

    • Subspecialty:
    • Spine

    • Clinical Practice Improvement

    • Basic Science

Neurovascular injuries to the athlete's shoulder: Part I.

The neurovascular structures traversing the shoulder region can be compromised in a number of ways. Athletes are particularly at risk of neurovascular injury to the shoulder as the result of extreme force and stress on the shoulder girdle. Many such injuries have been described in the literature as cervical radiculitis, spinal accessory nerve injury, long thoracic nerve palsy, burner (stinger) syndrome, and brachial neuritis. A high index of diagnostic acumen and proper selection of clinical assessment and imaging techniques are needed to diagnose such injuries.

    • Keywords:
    • Accessory Nerve|Athletic Injuries|Electrodiagnosis|Humans|Physical Therapy Modalities|Prognosis|Shoulder Joint|Thoracic Nerves|Thoracic Outlet Syndrome

    • Subspecialty:
    • Sports Medicine

    • Shoulder and Elbow

Osteonecrosis in the foot.

Osteonecrosis, also referred to as avascular necrosis, refers to the death of cells within bone caused by a lack of circulation. It has been documented in bones throughout the body. In the foot, osteonecrosis is most commonly seen in the talus, the first and second metatarsals, and the navicular. Although uncommon, osteonecrosis has been documented in almost every bone of the foot and therefore should be considered in the differential diagnosis when evaluating both adult and pediatric foot pain. Osteonecrosis is associated with many foot problems, including fractures of the talar neck and navicular as well as Kohler's disease and Freiberg's disease. Orthopaedists who manage foot disorders will at some point likely be faced with the challenges associated with patients with osteonecrosis of the foot. Because this disease can masquerade as many other pathologies, physicians should be aware of the etiology, presentation, and treatment options for osteonecrosis in the foot.

    • Keywords:
    • Diagnosis

    • Differential|Foot Bones|Foot Diseases|Humans|Internal Fixators|Orthopedic Procedures|Osteonecrosis|Prognosis

    • Subspecialty:
    • Trauma

    • Foot and Ankle

The rotator interval: anatomy, pathology, and strategies for treatment.

Over the past two decades, it has become accepted that the rotator interval is a distinct anatomic entity that plays an important role in affecting the proper function of the glenohumeral joint. The rotator interval is an anatomic region in the anterosuperior aspect of the glenohumeral joint that represents a complex interaction of the fibers of the coracohumeral ligament, the superior glenohumeral ligament, the glenohumeral joint capsule, and the supraspinatus and subscapularis tendons. As basic science and clinical studies continue to elucidate the precise role of the rotator interval, understanding of and therapeutic interventions for rotator interval pathology also continue to evolve. Lesions of the rotator interval may result in glenohumeral joint contractures, shoulder instability, or in lesions to the long head of the biceps tendon. Long-term clinical trials may clarify the results of current surgical interventions and further enhance understanding of the rotator interval.

    • Keywords:
    • Contracture|Humans|Joint Instability|Orthopedic Procedures|Range of Motion

    • Articular|Rotator Cuff|Shoulder Joint

    • Subspecialty:
    • Shoulder and Elbow

    • Basic Science

The use of lumbar epidural/transforaminal steroids for managing spinal disease.

Lumbar epidural steroid injections are used to manage low back and leg pain (ie, sciatica). Utilization of the procedure is increasing, with Medicare spending for lumbar epidural procedures topping $175 million annually. Few prospective randomized controlled trials have clearly demonstrated the efficacy of epidural steroid injections; many have shown conflicting results. Several studies show favorable short-term outcomes with epidural steroid injection for radicular pain, but less conclusive results are achieved >6 months. Methodologic flaws limit interpretation of results from most scientific studies. As a tool for predicting surgical outcome, epidural spinal injection has been found to have a sensitivity between 65% and 100%, a specificity between 71% and 95%, and a positive predictive value as high as 95% for 1-year surgical outcome. Despite inconclusive evidence, when weighing the surgical alternatives and associated risk, cost, and outcomes, lumbar epidural steroid injections are a reasonable nonsurgical option in select patients.

    • Keywords:
    • Glucocorticoids|Humans|Injections

    • Epidural|Low Back Pain|Lumbar Vertebrae|Spinal Diseases|Treatment Outcome

    • Subspecialty:
    • Spine

    • Pain Management

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