JAAOS

JAAOS, Volume 19, No. 8


Impact of Joint Laxity and Hypermobility on the Musculoskeletal System

Excessive joint laxity, or hypermobility, is a common finding of clinical importance in the management of musculoskeletal conditions. Hypermobility is common in young patients and in general is associated with an increased incidence of musculoskeletal injury. Hypermobility has been implicated in ankle sprains, anterior cruciate ligament injury, shoulder instability, and osteoarthritis of the hand. Patients with hypermobility and musculoskeletal injuries often seek care for diffuse musculoskeletal pain and injuries with no specific inciting event. Orthopaedic surgeons and other healthcare providers should be aware of the underlying relationship between hypermobility and musculoskeletal injury to avoid unnecessary diagnostic tests and inappropriate management. Prolonged therapy and general conditioning are typically required, with special emphasis on improving strength and proprioception to address symptoms and prevent future injury. Orthopaedic surgeons must recognize the implications of joint mobility syndromes in the management and rehabilitation of several musculoskeletal injuries and orthopaedic disorders.

      • Subspecialty:
      • Shoulder and Elbow

      • Hand and Wrist

    Intramedullary Nailing of Pediatric Femoral Shaft Fracture

    Intramedullary nail fixation of pediatric long bone fracture, particularly femoral shaft fracture, has revolutionized the care and outcome of these complex injuries. Nailing is associated with a high rate of union and a low rate of complications. Improved understanding of proximal femoral vascularity has led to changes in nail insertion methodology. Multiple fixation devices are available; selection is based on fracture type, patient age, skeletal maturity, and body mass index. A thorough knowledge of anatomy and biomechanics is required to achieve optimal results without negatively affecting skeletal development.

        • Subspecialty:
        • Trauma

      Lesser Toe Deformities

      Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. Causes include improper shoe wear, trauma, genetics, inflammatory arthritis, and neuromuscular and metabolic diseases. Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux valgus of the first MTP joint and instability of the lesser MTP joints, especially the second toe. Midfoot and hindfoot deformities (eg, cavus foot, varus hindfoot, valgus hindfoot with forefoot pronation) may be present, as well. Nonsurgical management focuses on relieving pressure and correcting deformity with various appliances. Surgical management is reserved for patients who fail nonsurgical treatment. Options include soft-tissue correction (eg, tendon transfer) as well as bony procedures (eg, joint resection, fusion, metatarsal shortening), or a combination of techniques.

          • Subspecialty:
          • Foot and Ankle

        Osteonecrosis of the Knee and Related Conditions

        Osteonecrosis (ON) of the knee is a progressive disease that often leads to subchondral collapse and disabling arthritis. Recent studies have identified three distinct pathologic entities, all of which were previously described as knee ON: secondary ON, spontaneous ON of the knee, and postarthroscopic ON. Radiographic and clinical assessment is useful for differentiating these conditions, predicting disease progression, and distinguishing these conditions from other knee pathologies. The etiology, pathology, and pathogenesis of secondary ON of the knee are similar to those found at other sites (eg, hip, shoulder). Spontaneous ON is a disorder of unknown etiology. Postarthroscopic ON has been described as an infrequent but potentially destructive complication. Various treatment modalities (eg, core decompression, bone grafting, high tibial osteotomy, arthroplasty), have been used with varying degrees of success for each type of ON. Secondary ON frequently progresses to end-stage disease, and early surgical intervention is recommended. Initial management of spontaneous ON of the knee and postarthroscopic ON is typically nonsurgical, with observation for clinical or radiographic progression.

            • Subspecialty:
            • Sports Medicine

          Scapular Winging: An Update

          Scapular winging is a rare disorder often caused by neuromuscular imbalance in the scapulothoracic stabilizer muscles. Lesions of the long thoracic nerve and spinal accessory nerves are the most common cause. Numerous underlying etiologies have been described. Patients report diffuse neck, shoulder girdle, and upper back pain, which may be debilitating, associated with abduction and overhead activities. Accurate diagnosis and detection depend on appreciation of the scapulothoracic anatomy and a comprehensive physical examination. Although most cases resolve nonsurgically, surgical treatment of scapular winging has been met with success.

              • Subspecialty:
              • Shoulder and Elbow

            Vascular Injury Associated With Extremity Trauma: Initial Diagnosis and Management

            Vascular injury associated with extremity trauma occurs in <1% of patients with long bone fracture, although vascular injury may be seen in up to 16% of patients with knee dislocation. In the absence of obvious signs of vascular compromise, limb-threatening injuries are easily missed, with potentially devastating consequences. A thorough vascular assessment is essential; an arterial pressure index <0.90 is indicative of potential vascular compromise. Advances in CT and duplex ultrasonography are sensitive and specific in screening for vascular injury. Communication between the orthopaedic surgeon and the vascular or general trauma surgeon is essential in determining whether to address the vascular lesion or the orthopaedic injury first. Quality evidence regarding the optimal fixation method is scarce. Open vascular repair, such as direct repair with or without arteriorrhaphy, interposition replacement, and bypass graft with an autologous vein or polytetrafluoroethylene, remains the standard of care in managing vascular injury associated with extremity trauma. Although surgical technique affects outcome, results are primarily dependent on early detection of vascular injury followed by immediate treatment.

                • Subspecialty:
                • Trauma

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