JAAOS

JAAOS, Volume 18, No. 1


Ambulatory assistive devices in orthopaedics: uses and modifications.

Ambulatory assistive devices (eg, canes, crutches, walkers) provide advantages such as stability, augmentation of muscle action, and reduction of weight-bearing load. Although they are often prescribed, a detailed understanding of these devices is often lacking, which can lead to detrimental consequences. Comprehension of normal gait cadence, as well as the gait patterns used in both reciprocating and swinging gait, allows the orthopaedic surgeon to understand the limitations of the patient with gait abnormalities. Appreciating the types of assistive devices, their modifications, associated gait patterns, physiologic demand, proper fitting, and indications for use is essential in prescribing the proper device.

    • Keywords:
    • Canes|Crutches|Equipment Design|Gait|Hip Joint|Humans|Muscle

    • Skeletal|Orthopedic Equipment|Self-Help Devices|Walkers|Weight-Bearing

    • Subspecialty:
    • General Orthopaedics

    • Basic Science

Current treatment strategies for bicolumnar distal humerus fractures.

Management of distal humerus fractures continues to challenge orthopaedic surgeons. The unique and complex anatomy of the distal humerus, involving the ulnohumeral and radiocapitellar joints, makes anatomic reduction difficult and hardware placement challenging. However, long-term results of well-performed open reduction and internal fixation demonstrate satisfactory outcomes in most patients. Osteoporosis in the elderly population often leads to severe comminution, which may render open reduction and internal fixation impossible. Total elbow arthroplasty in the elderly has become a viable option, with excellent results in the properly selected patient who understands the lifetime limitations of this option. Distal humeral replacement is a new and potentially exciting option but it is currently not approved by the US Food and Drug Administration and has no long-term follow-up to support its use.

    • Keywords:
    • Arthrodesis|Arthroplasty|Bone Plates|Elbow Joint|Fracture Fixation

    • Internal|Humans|Humeral Fractures|Humerus|Ossification

    • Heterotopic|Physical Therapy Modalities|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

    • Adult Reconstruction

Distal triceps rupture.

Distal triceps rupture is an uncommon injury. It is most often associated with anabolic steroid use, weight lifting, and laceration. Other local and systemic risk factors include local steroid injection, olecranon bursitis, and hyperparathyroidism. Distal triceps rupture is usually caused by a fall on an outstretched hand or a direct blow. Eccentric loading of a contracting triceps has been implicated, particularly in professional athletes. Initial diagnosis may be difficult because a palpable defect is not always present. Pain and swelling may limit the ability to evaluate strength and elbow range of motion. Although plain radiographs are helpful in ruling out other elbow pathology, MRI is used to confirm the diagnosis, classify the injury, and guide management. Incomplete tears with active elbow extension against resistance are managed nonsurgically. Surgical repair is indicated in active persons with complete tears and for incomplete tears with concomitant loss of strength. Good to excellent results have been reported with surgical repair, and very good results have been achieved even for chronic tears.

    • Keywords:
    • Elbow Joint|Humans|Magnetic Resonance Imaging|Physical Examination|Postoperative Care|Range of Motion

    • Articular|Reoperation|Rupture|Suture Techniques|Tendon Injuries|Tendons

    • Subspecialty:
    • Sports Medicine

    • Shoulder and Elbow

    • Hand and Wrist

Extremity war injuries: collaborative efforts in research, host nation care, and disaster preparedness.

The fourth annual Extremity War Injuries (EWI) Symposium addressed ongoing challenges and opportunities in the management of combat-related musculoskeletal injury. The symposium, which also examined host-nation care and disaster preparedness and response, defined opportunities for synergy between several organizations with similar missions and goals. Within the Department of Defense, the Orthopaedic Extremity Trauma Research Program (OETRP) has funded basic research related to a series of protocols first identified and validated at prior EWI symposia. A well-funded clinical research arm of OETRP has been developed to help translate and validate research advances from each of the protocols. The Armed Forces Institute for Regenerative Medicine, a consortium of academic research institutions, employs a tissue-engineering approach to EWI challenges, particularly with regard to tissue loss. Programs within the National Institute of Arthritis and Musculoskeletal and Skin Diseases and throughout the National Institutes of Health have also expanded tissue-engineering efforts by emphasizing robust mechanistic basic science programs. Much of the clinical care delivered by US military medical personnel and nongovernmental agencies has been to host-nation populations; coordinating delivery to maximize the number of injured who receive care requires understanding of the breadth and scope of resources available within the war zone. Similarly, providing the most comprehensive care to the greatest number of injured in the context of domestic mass casualty requires discussion and planning by all groups involved.

    • Keywords:
    • Disaster Planning|Extremities|Humans|Military Medicine|Military Personnel|Tissue Engineering|United States|War

    • Subspecialty:
    • Trauma

    • Clinical Practice Improvement

Open tibial shaft fractures: I. Evaluation and initial wound management.

Open fractures of the tibial diaphysis are often associated with severe bone and soft-tissue injury. Contamination of the fracture site and devitalization of the soft-tissue envelope greatly increase the risk of infection, nonunion, and wound complications. Management of open tibial shaft fractures begins with a thorough patient evaluation, including assessment of the bone and soft tissue surrounding the tibial injury. Classification of these injuries according to the system of Gustilo and Anderson at the time of surgical débridement is useful in guiding treatment and predicting outcomes. Administration of antibiotic prophylaxis as soon as possible after injury as well as urgent and thorough débridement, irrigation, and bony stabilization are done to minimize the risk of infection and improve outcomes. The use of antibiotic bead pouches and negative-pressure wound therapy has proved to be efficacious for the acute, temporary management of severe bone and soft-tissue defects.

    • Keywords:
    • Algorithms|Antibiotic Prophylaxis|Bone Cements|Debridement|Fractures

    • Open|Humans|Irrigation|Negative-Pressure Wound Therapy|Polymethyl Methacrylate|Tibial Fractures|Wound Healing

    • Subspecialty:
    • Trauma

The advantage of throwing the first stone: how understanding the evolutionary demands of Homo sapiens is helping us understand carpal motion.

Unlike any other diarthrodial joint in the human body, the "wrist joint" is composed of numerous articulations between eight carpal bones, the distal radius, the distal ulna, and five metacarpal bones. The carpal bones articulate with each other as well as with the distal radius, distal ulna, and the metacarpal bases. Multiple theories explaining intercarpal motion have been proposed; however, controversy exists concerning the degree and direction of motion of the individual carpal bones within the two carpal rows during different planes of motion. Recent investigations have suggested that traditional explanations of carpal bone motion may not entirely account for carpal motion in all planes. Better understanding of the complexities of carpal motion through the use of advanced imaging techniques and simultaneous appreciation of human anatomic and functional evolution have led to the hypothesis that the "dart thrower's motion" of the wrist is uniquely human. Carpal kinematic research and current developments in both orthopaedic surgery and anthropology underscore the importance of the dart thrower's motion in human functional activities and the clinical implications of these concepts for orthopaedic surgery and rehabilitation.

    • Keywords:
    • Anthropology

    • Physical|Biomechanics|Carpal Bones|Evolution|Hand Strength|Humans|Imaging

    • Three-Dimensional|Range of Motion

    • Articular|Wrist Joint

    • Subspecialty:
    • Sports Medicine

    • Hand and Wrist

    • Basic Science

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