JAAOS

JAAOS, Volume 17, No. 4


Achondroplasia: manifestations and treatment.

Achondroplasia, the most common skeletal dysplasia, is caused by a mutation of fibroblast growth factor receptor-3. This disorder is characterized by frontal bossing, midface hypoplasia, otolaryngeal system dysfunction, and rhizomelic short stature. Orthopaedic manifestations are exhibited in the spine and the extremities. In the infant with achondroplasia, foramen magnum stenosis may result in brainstem compression with apnea and sudden death. Thoracolumbar kyphosis is seen in most infants, but typically it resolves when the child begins to walk. Anatomic anomalies of the vertebral column place the patient at risk for spinal stenosis as early as the first decade and especially during adulthood. Radial head dislocation is one manifestation in the upper extremity. Lower extremity alignment often is characterized by genu varum, which may require correction osteotomy. Medical and surgical options are available to increase patient height, but indications are controversial, and treatment often consumes a large portion of the child's life.

    • Keywords:
    • Achondroplasia|Foramen Magnum|Humans|Kyphosis|Lordosis|Orthopedic Procedures|Spinal Stenosis

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

Acromioclavicular joint injuries: diagnosis and management.

Acromioclavicular joint injuries represent nearly half of all athletic shoulder injuries, often resulting from a fall onto the tip of the shoulder with the arm in adduction. Stability of this joint depends on the integrity of the acromioclavicular ligaments and capsule as well as the coracoclavicular ligaments and the trapezius and deltoid muscles. Along with clinical examination for tenderness and instability, radiographic examination is critical in the evaluation of acromioclavicular joint injuries. Nonsurgical treatment is indicated for type I and II injuries; surgery is almost always recommended for type IV, V, and VI injuries. Management of type III injuries remains controversial, with nonsurgical treatment favored in most instances and reconstruction of the acromioclavicular joint reserved for symptomatic instability. Recommended techniques for stabilization in cases of acute and late symptomatic instability include screw fixation of the coracoid process to the clavicle, coracoacromial ligament transfer, and coracoclavicular ligament reconstruction. Biomechanical studies have demonstrated that anatomic acromioclavicular joint reconstruction is the most effective treatment for persistent instability.

    • Keywords:
    • Acromioclavicular Joint|Athletic Injuries|Biomechanics|Bone Screws|Humans|Joint Instability|Ligaments

    • Articular|Orthopedic Procedures

    • Subspecialty:
    • Trauma

    • Sports Medicine

    • Shoulder and Elbow

Controversies in the treatment of knee dislocations and multiligament reconstruction.

A systematic approach to evaluation and treatment is needed for the patient with knee dislocation. There is a paucity of high-level evidence on which to base treatment decisions. Reported controversies related to the treatment of the multiligament-injured knee include the selective use of arteriography for vascular assessment, serial physical examination with the ankle-brachial index, acute surgical treatment of all damaged structures, the selective application of preoperative and postoperative joint-spanning external fixation, arthroscopic reconstruction of the anterior cruciate ligament and posterior cruciate ligament, simultaneous open reconstruction with repair of the posterolateral corner, reconstruction and/or repair of the posteromedial corner, and the use of allograft tissue.

    • Keywords:
    • Ankle Brachial Index|Anterior Cruciate Ligament|Arthroscopy|External Fixators|Humans|Knee Dislocation|Posterior Cruciate Ligament|Transplantation

    • Homologous

    • Subspecialty:
    • Sports Medicine

Distal fibula malunions.

Anatomic reduction and fixation of unstable ankle fractures is necessary to prevent posttraumatic arthritis. Malunion of the distal fibula in unstable ankle fractures may lead to progressive talar instability. Ankle fracture malunions often present with concomitant syndesmotic widening, which can cause surgeons to overlook changes in fibula length and rotation. The decision to proceed with surgery should be made only after a careful diagnostic workup and detailed preoperative discussion with the patient. Considerations for surgical management include location and orientation of a corrective osteotomy, use of structural graft, widening of the syndesmosis, assessment of reduction, and the need for medial exposure. Good and excellent clinical results after fibular reconstruction have been reported in 67% to 92% of ankles. Proper patient selection is critical, because ankle malunions can be complicated, with coexisting fibular, syndesmotic, medial, and posterior malleolar malalignment, along with degenerative joint disease. Understanding the indications and surgical technique for revising fibular malunions may obviate a future salvage procedure.

    • Keywords:
    • Ankle Injuries|Fibula|Fractures

    • Bone|Fractures

    • Malunited|Humans|Joint Instability|Orthopedic Procedures|Salvage Therapy

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Pathoanatomy and clinical correlates of the immunoinflammatory response following orthopaedic trauma.

The natural inflammatory response to major trauma may be associated with the development of a systemic inflammatory state, remote multiorgan failure, and death. Although a controlled inflammatory response is beneficial, an exaggerated response can cause serious adverse systemic effects. Early identification of high-risk patients, based on inflammatory markers and genomic predisposition, should help direct intervention in terms of surgical stabilization and biologic response modification. Currently, two markers of immune reactivity, interleukin-6 and human leukocyte antigen-DR class II molecules, appear to have the most potential for regular use in predicting the clinical course and outcome in trauma patients; however, the ability to measure markers of inflammation is still limited at many hospitals. With improving technology and increasing research interest, understanding of the significance of the immunoinflammatory response system in injured patients will continue to evolve.

    • Keywords:
    • Biological Markers|HLA-DR Antigens|Humans|Inflammation|Interleukin-6|Multiple Trauma|Orthopedic Procedures|Prognosis

    • Subspecialty:
    • Trauma

    • Basic Science

Shoulder problems in children with brachial plexus birth palsy: evaluation and management.

Traction injury to the brachial plexus sustained during the birth process that results in impaired neuromuscular function of the upper extremity continues to occur despite advances in modern obstetric care. The most common pattern of injury usually results in motor weakness of shoulder external rotation, leading to internal rotation contractures and subsequent deformity of the skeletally immature glenohumeral joint. Understanding of these deformities and effective surgical intervention have advanced greatly over the past decade. Restoration of balance between internal and external rotation forces around the shoulder has great potential for remodeling of the glenohumeral joint in the young child. Arthroscopic-directed release of the contracture, with select use of latissimus dorsi transfer to provide external rotation power, has proved to be effective for many children with these contractures.

    • Keywords:
    • Birth Injuries|Brachial Plexus Neuropathies|Contracture|Humans|Orthopedic Procedures|Range of Motion

    • Articular|Shoulder Joint

    • Subspecialty:
    • Pediatric Orthopaedics

    • Shoulder and Elbow

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