JAAOS

JAAOS, Volume 19, No. 4


Coracoid Impingement: Diagnosis and Treatment

Coracoid impingement is a controversial, well-known diagnosis that results in anterior shoulder pain. Idiopathic, traumatic, and iatrogenic etiologies have been identified. Proper diagnosis requires a focused clinical examination of the anterior shoulder and adjacent structures. MRI and CT are helpful in evaluating coracoid morphology as well as the integrity of the rotator cuff and long head of the biceps. Imaging is an essential diagnostic tool. Initial management consists of physical therapy and injection therapies. Surgery may be required when nonsurgical methods are unsuccessful. Successful functional and subjective outcomes have been reported with both open and arthroscopic techniques.

      • Subspecialty:
      • Sports Medicine

      • Shoulder and Elbow

    Infection After Shoulder Surgery

    Infection after shoulder surgery is rare but potentially devastating. Normal skin flora, including Staphylococcus aureus, Staphylococcus epidermidis, and Propionibacterium acnes, are the most commonly isolated pathogens. Perioperative measures to prevent infection are of paramount importance, and clinical acumen is necessary for diagnosis. Superficial infections may be managed with local wound measures and antibiotics; deep infections require surgical dbridement in combination with antibiotic treatment. Treating physicians must make difficult decisions regarding antibiotic duration and the elimination of the offending organisms by resection arthroplasty, direct implant exchange, or staged revision arthroplasty. Eradication of a deep infection is usually successful, but the course of treatment is often protracted, and tissue destruction and scar may adversely affect functional outcome.

        • Subspecialty:
        • Sports Medicine

        • Shoulder and Elbow

        • Clinical Practice Improvement

      Orthopaedic Aspects of All-terrain Vehiclerelated Injury

      Despite an abundance of evidence on the morbidity and mortality associated with all-terrain vehicle (ATV) accidents, use of ATVs continues to increase, with corresponding increases in the frequency of associated injury and death. Children and adolescents account for a disproportionately large percentage of injuries. However, the number of accidents involving persons aged >50 years is increasing, as well. Legislative and educational initiatives have been unsuccessful in substantially reducing the number of ATV-related injuries and deaths. Because musculoskeletal injury is commonly associated with ATV accidents, orthopaedic surgeons have the opportunity to play a pivotal role in the prevention and management of ATV-related injury and death.

          • Subspecialty:
          • Trauma

        Patellar Fractures in Adults

        Patellar fracture is a common injury caused by excessive tension through the extensor mechanism or a direct blow. The intact patella increases the leverage and efficiency of the extensor mechanism and articulates with the femoral trochlea. Patellar fractures can lead to stiffness, extension weakness, and patellofemoral arthritis. Nonsurgical management is indicated for nondisplaced fractures with an intact extensor mechanism. Surgical fixation is recommended for fractures that either disrupt the extensor mechanism or demonstrate >2 to 3 mm step-off and >1 to 4 mm of displacement. Anatomic reduction and fixation with a tension-band technique is associated with the best outcomes; however, symptomatic hardware is a frequent complication. Open fractures are associated with more complications than closed fractures. These complications can be mitigated with timely dbridement, irrigation, and internal fixation.

            • Subspecialty:
            • Trauma

          The Role of Arthroscopy in the Management of Fractures About the Ankle

          Anatomic restoration of the joint is the goal of management in fractures about the ankle. Open reduction and internal fixation (ORIF) is the standard of care for unstable ankle fractures; however, arthroscopic management has been proposed. The use of arthroscopic reduction and internal fixation (ARIF) is surgeon-dependent. Reported indications for ARIF include transchondral talar dome fracture, talar fracture, low-grade fracture of the distal tibia, syndesmotic disruption, malleolar fracture, and chronic pain following definitive management of fracture about the ankle. Among the potential benefits are less extensive exposure, preservation of blood supply, and improved visualization of the pathology. Although arthroscopy is increasingly used in the setting of trauma, the effectiveness of ARIF compared with ORIF for management of fractures of the distal tibia, malleolus, displaced talar neck, and talar body has yet to be determined. Most of these fractures are effectively managed with open procedures.

              • Subspecialty:
              • Trauma

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