JAAOS

JAAOS, Volume 3, No. 2


Fractures and Dislocations of the Forefoot: Operative and Nonoperative Treatment.

Effective treatment of common bone injuries of the forefoot is dependent on a clear understanding of both the osseous anatomy of the foot and the biomechanics of gait. Obtaining a thorough history and performing a careful physical examination are especially important because the complex anatomy of the region often makes radiographic diagnosis difficult. The keys to making the correct diagnosis in the injured forefoot are detailed, with emphasis on obtaining the appropriate radiographic studies. Included in the discussion are injuries to Lisfranc's joint and the metatarsophalangeal and sesamoid joints, as well as metatarsal and phalangeal fractures. Guidelines for operative and nonoperative management of these injuries are presented.

      • Subspecialty:
      • Trauma

      • Foot and Ankle

      • Basic Science

    Fractures of the Proximal Fifth Metatarsal: Selecting the Best Treatment Option.

    Because of circulatory differences in the three zones of the proximal fifth metatarsal, the location of a fracture must be considered when selecting treatment. The most proximal portion of the base of the fifth metatarsal has good blood supply. Fractures in this zone usually extend into the fifth metatarsocuboid joint. The second zone is associated with Sir Robert Jones, who in 1902 first asserted that fractures of the fifth metatarsal are commonly caused by indirect violence. Fractures in this zone take longer to heal than more proximal fractures, and treatment should be individualized. Whether to use a functional metatarsal brace, a stiff-soled shoe, a short-leg cast, or even internal fixation with a screw depends on the patient's lifestyle and desired activity level. Fractures in the third zone occur between the distalmost portion of the metaphysis and the proximal 1.5 cm of the diaphyseal tubular bone. This zone begins just distal to the ligamentous complex holding the proximal fourth and fifth metatarsals together. In active athletes, fractures in this zone often are stress injuries. For anatomic and mechanical reasons, such fractures are the most difficult to heal. Without surgical treatment, they may take 2 to 21 months to unite and are therefore more likely to need aggressive treatment.

        • Subspecialty:
        • Trauma

        • Foot and Ankle

      Physeal Fractures About the Knee.

      The knee is the most common site of injury in childhood sports, and with increased participation in organized sports, the potential for knee injuries has accordingly increased. The epiphyses and apophyses provide a site of injury unique to the immature patient. The distal femoral and proximal tibial physes and the tubercle apophysis respond differently to acute and repetitive load and often provide less resistance to traumatic forces than do surrounding ligament and bone. Treatment of displaced physeal fractures about the knee remains one of the more difficult problems in orthopaedics. Even with appropriate conservative or surgical treatment, a successful outcome is not ensured. The Salter-Harris classification system provides general guidelines regarding the risk of growth disturbance, but there are no clinical methods for quantifying the true extent of physeal damage in an acute injury. Ultimately, the value of a treatment method must be evaluated on the basis of not only the restoration of articular congruity and physeal anatomy but also the restoration of physeal function, as evidenced by the continuation of normal growth. The mechanism of injury, clinical evaluation, treatment, and outcomes for all epiphyseal injuries about the knee are discussed, as well as differences from adult injuries.

          • Subspecialty:
          • Trauma

          • Sports Medicine

          • Pediatric Orthopaedics

        Revision Total Hip Arthroplasty: The Femoral Component.

        The initial results with cemented femoral revision stems were disappointing, with high early loosening rates. The application of second-generation cementing techniques improved results markedly, with loosening rates of 10% at 10 years in a number of series. Bone quality and patient age also appear to be important factors in predicting the success with a cemented revision stem. The use of a long stem is not necessary to obtain these improved results. On the basis of early reports, a recently described technique in which a revision stem is cemented into impacted cancellous allograft appears promising. Results with proximally coated uncemented revision stems have been variable, with failure rates of 4% to 10% reported at only 2 to 4 years. Initial stability must be obtained if proximal coating is to be utilized. Extensively coated revision stems provide initial stability through an interference fit between the porous coating and the diaphysis. With this technique, 10-year survival rates of 90% have been achieved, and the clinical results appear to be equivalent to those obtained with cemented revision stems and modern cementing techniques. Diaphyseal fixation has also been achieved without porous coating, either with modular revision stems or with long, textured titanium stems. Isolated early reports with such stems have been promising, but 10-year results are not yet available.

            • Subspecialty:
            • Trauma

            • Adult Reconstruction

          The Distal Radioulnar Joint: Problems and Solutions.

          Disorders of the distal radioulnar joint are a major source of ulnar-sided wrist pain. Fortunately, our understanding of the anatomy, joint mechanics, and pathophysiology of this area has increased greatly in recent years, making resolution of many of these problems feasible. In most cases, an accurate diagnosis can be made, and successful treatment can then be prescribed. This review covers various problems affecting the distal radioulnar joint, including fractures and dislocations, triangular fibrocartilage pathology, arthritis, and other disorders.

              • Subspecialty:
              • Hand and Wrist

              • Basic Science

            Tibial Plateau Fractures: Evaluation and Treatment.

            The goal of tibial plateau fracture management is a stable, well-aligned, congruent joint, with a painless range of motion and function. Minimally displaced stable fractures should be treated with protected mobilization. The treatment of displaced tibial plateau fractures, however, remains controversial. Surgical reduction and stabilization of displaced tibial plateau fractures, when indicated, requires careful evaluation of both the "personality" of the fracture and the soft-tissue envelope. The timing of surgery and the handling of the soft tissue in this region are critical to treatment success. After restoration of a congruent joint surface, bone grafting and buttress plating are usually needed to allow early range of motion and optimize treatment outcome.

                • Subspecialty:
                • Trauma

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