JAAOS

JAAOS, Volume 19, No. 1


Acute Compartment Syndrome of the Upper Extremity

Acute compartment syndrome occurs when pressure within a fibro-osseous space increases to a level that results in a decreased perfusion gradient across tissue capillary beds. Compartment syndromes of the hand, forearm, and upper arm can result in tissue necrosis, which can lead to devastating loss of function. The etiology of acute compartment syndrome in the upper extremity is diverse, and a high index of suspicion must be maintained. Pain out of proportion to injury is the most reliable early symptom of impending compartment syndrome. Diagnosis is particularly difficult in obtunded patients and in young children. Early recognition and expeditious surgical treatment are essential to obtain a good clinical outcome and prevent permanent disability.

      • Subspecialty:
      • Trauma

      • Sports Medicine

      • Shoulder and Elbow

    Femoral Malrotation Following Intramedullary Nail Fixation

    Intramedullary nailing of femoral shaft fracture can result in inadvertent malalignment. Malrotation is the most common cause of deformity, but it is underrecognized, in part because of the difficulty in accurately assessing rotation as well as the variation that exists in normal anatomy. The consequences of femoral malrotation are not completely understood. However, initial biomechanical studies suggest that it causes a substantial change in load bearing in the affected extremity. Clinical examination, fluoroscopy, and ultrasonography are useful in measuring femoral rotational alignment intraoperatively and postoperatively. CT is useful in the identification of the degree of malrotation and in surgical planning.

        • Subspecialty:
        • Trauma

      Management of Calcaneal Malunion

      The potential for disabling malunion following calcaneal fracture is high, regardless whether a patient is treated nonsurgically or surgically. Fracture displacement typically results in loss of hindfoot height, varus heel position, and widening of the hindfoot, with possible subfibular impingement and irritation of the peroneal tendon and/or sural nerve. Frequently, the subtalar joint develops posttraumatic arthritis. In symptomatic patients with calcaneal malunion, systematic evaluation is required to determine the source of pain. Nonsurgical treatment, such as activity modification, bracing, orthoses, and injection, is effective in many patients. Surgical treatment may involve simple ostectomy, subtalar arthrodesis with or without distraction, or corrective calcaneal osteotomy. A high rate of successful arthrodesis and of patient satisfaction has been reported with surgical management.

          • Subspecialty:
          • Trauma

          • Foot and Ankle

        Management of Traumatic Sternoclavicular Joint Injuries

        Traumatic sternoclavicular joint injuries account for <3% of all traumatic joint injuries. Proper recognition and treatment are vital because these injuries may be life threatening. Injuries are classified according to patient age, severity, and, in the setting of dislocation, the direction of the medial clavicle. Anterior injuries are far more common than posterior injuries. Posterior dislocation may be associated with complications such as dyspnea, dysphagia, cyanosis, and swelling of the ipsilateral extremity as well as paresthesia associated with compression of the trachea, esophagus, or great vessels. These life-threatening complications may present at the time of injury but can develop later, as well. Radiography has been largely supplanted by CT for evaluation of this injury, although an oblique view developed by Wirth and Rockwood is useful in evaluating isolated sternoclavicular injury. MRI is useful in differentiating physeal injury from sternoclavicular dislocation in patients aged <23 years.

            • Subspecialty:
            • Trauma

            • Shoulder and Elbow

          Metastatic Disease in the Thoracic and Lumbar Spine: Evaluation and Management

          Spinal metastases are found in most patients who die of cancer. The number of patients with symptomatic spinal metastases likely will increase as therapy for the primary disease improves and as cardiovascular mortality decreases. Understanding the epidemiology of metastatic spine disease and its presentation is essential to developing a diagnostic strategy. Treatment may involve chemotherapy, corticosteroids, radiotherapy, surgery, and/or percutaneous procedures (eg, vertebroplasty, kyphoplasty). A rational treatment plan can help improve quality of life, preserve neurologic function, and prolong survival.

              The Role of Trochlear Dysplasia in Patellofemoral Instability

              Trochlear dysplasia is characterized by abnormal trochlear morphology and a shallow groove. It is associated with recurrent patellar dislocation, but it is unclear whether the dysplasia is congenital, the result of lateral tracking and chronic instability, or caused by a combination of factors. Lateral radiographs elucidate the crossing sign and characteristic trochlear prominence. Recurrent patellofemoral instability is multifactorial, and each component must be considered in determining treatment. Managing other factors associated with recurrent instability may compensate for a deficient trochlea and provide stability. Medial patellofemoral ligament reconstruction is recommended for patellofemoral instability in the presence of trochlear dysplasia in patients without patella alta or increased tibial tubercletrochlear groove distance. Trochleoplasty should be reserved for severe dysplasia in which patellofemoral stability cannot otherwise be obtained.

                  • Subspecialty:
                  • Sports Medicine

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