JAAOS

JAAOS, Volume 3, No. 3


Anterior Cruciate Ligament Injury in the Skeletally Immature Patient: Diagnosis and Treatment.

Significant intra-articular knee injuries, including tears of the anterior cruciate ligament (ACL), are now being recognized more frequently in skeletally immature patients. Previously reported data on ACL tears in this age group are sparse, and studies have been of limited quality. Improvements in diagnostic techniques (e.g., physical examination signs, arthrometric testing, magnetic resonance imaging, and arthroscopy) have facilitated identification of such injuries. Hemarthrosis must be regarded as a herald of a major intra-articular injury. Surgical reconstruction options vary according to the specific diagnosis and the stage of maturity, and the available options for the very skeletally immature patient are limited. Therefore, treatment must be predicated on assessment of maturity, as determined on the basis of chronologic, radiologic, and physiologic criteria. An ACL injury in this age group is not a surgical emergency; therefore, time for discussion with the patient and his or her parents is available, so that all appropriate options can be considered.

      • Subspecialty:
      • Sports Medicine

      • Pediatric Orthopaedics

    Disorders of the Lesser Metatarsophalangeal Joints.

    Pain in the region of the lesser metatarsophalangeal joints (often termed metatarsalgia) is a common complaint. It can be due to a variety of causes, and accurate diagnosis is essential for effective treatment. Understanding the anatomy and functions of the extrinsic and intrinsic musculature and the plantar plate, ligaments, and fat pad is important in evaluating metatarsophalangeal joint disorders. Claw toe is a hyperextension deformity of the metatarsophalangeal joint in combination with a hammer toe. Pathologic changes involving an isolated metatarsophalangeal joint may be due to monarticular synovitis. Systemic inflammatory disorders can cause variable degrees of instability, resulting in sub-luxation or dislocation. Other specific disorders at the lesser metatarsophalangeal joints include discrete and diffuse intractable plantar keratoses, Freiberg's infraction, and cock-up fifth toe. Once the specific pathologic entity has been determined, the appropriate course of nonsurgical or, if necessary, operative treatment can be instituted.

        • Subspecialty:
        • Trauma

        • Foot and Ankle

      Hip Arthroscopy: Applications and Technique.

      Hip arthroscopy is infrequently performed in North America. The anatomic constraints of the joint and the lack of equipment specifically designed for this application have contributed to the lack of surgical experience. Because of the potential for significant neurovascular injury, familiarization with precise portal placement is essential. In properly selected patients, hip arthroscopy allows diagnosis of a variety of disorders. The authors believe this technique has a significant role in the treatment of acetabular labral tears, loose bodies, chondral injuries to the joint, and septic arthritis.

          • Subspecialty:
          • Trauma

          • Adult Reconstruction

        Lumbar Spine Fusion in the Treatment of Degenerative Conditions: Current Indications and Recommendations.

        The role of arthrodesis in the treatment of degenerative disorders of the lumbar spine is controversial. Most patients with these conditions can be successfully treated nonoperatively. Lumbar fusion, with or without instrumentation, is associated with more complications, especially in the elderly population. Therefore, the potential benefits to be obtained by means of arthrodesis must be measured against the risks. Arthrodesis is indicated as an adjunct to decompression for patients with spinal stenosis associated with degenerative or iatrogenic spondylolisthesis and in the treatment of progressive degenerative lumbar scoliosis and iatrogenic instability resulting from extensive decompression. The occurrence of two or more episodes of disk herniation at the same segment is a relative indication for arthrodesis. In patients with incapacitating nonradicular back pain, arthrodesis should be a consideration only after failure of a trial of nonoperative treatment lasting more than 12 months and after secondary gain issues (e.g., workmen's compensation) have been adequately resolved. Arthrodesis has a poor success rate when used to treat back pain associated with multilevel disk degeneration seen on magnetic resonance images.

            • Subspecialty:
            • Spine

          Shoulder Injuries in the Throwing Athlete.

          The throwing athlete with shoulder pain presents a diagnostic and treatment challenge to the orthopaedic surgeon. Because pitching a baseball requires the arm to accelerate at 7,000 degrees per second, tremendous forces are experienced at the shoulder joint. Electromyographic studies have shown that the larger scapular and trunk muscles are primarily responsible for arm acceleration. The smaller and more fragile rotator cuff muscles play a significant role in decelerating the arm. During the entire throwing mechanism, the rotator cuff and the capsulolabral complex act to stabilize the humeral head on the glenoid fossa. As a result, the labrum, the capsule, and the rotator cuff are frequently the site of shoulder injury in throwers. The diagnosis of injury to these structures is based on the findings from the history, physical examination, and imaging studies. The majority of throwing injuries respond well to a carefully designed rehabilitation program. Athletes who do not improve within 6 months are candidates for surgical repair. The procedure is planned so as to minimize the amount of surgical trauma and thereby to facilitate an early return to sport. Arthroscopy is a valuable first step to confirm the pathologic diagnosis. The arthroscope alone is used to perform subacromial debridement, labral repair, or debridement of undersurface partial-thickness rotator cuff tears. If the athlete has clinical evidence of shoulder instability and arthroscopic evidence of capsular stretch, an open stabilization procedure is performed.

              • Subspecialty:
              • Trauma

              • Sports Medicine

              • Shoulder and Elbow

            Skeletal Dysplasias: An Approach to Diagnosis.

            Skeletal dysplasias are the result of aberration in the growth and development of the skeleton. While they are individually rare, they are important in that they provide an insight into the mechanism of skeletal development. This article offers an approach to the diagnosis of skeletal dysplasias, rather than an exhaustive account of all the possible diagnoses. Dysplastic conditions are suspected on the basis of abnormal stature, disproportion, dysmorphism, or deformity. Diagnosis requires simple measurement of height and calculation of proportionality, combined with a complete physical examination, appropriate radiographs, an investigation of the family pedigree, and occasionally laboratory studies. An accurate diagnosis can usually be made on the basis of these data and a review of descriptive sources. A definitive diagnosis allows the treating physician to project the patient's ultimate height and to prognosticate about likely deformities and the risk of the recurrence of the condition in the family.

                • Subspecialty:
                • General Orthopaedics

              The Foot in Running.

              Injuries to the foot and ankle are often encountered in runners, be they highlevel competitors or recreational joggers. Many of these injuries are due to overuse syndromes and training errors; others are related to the running surface or the athlete's footwear. Only with a rational approach to diagnosis can the primary underlying cause be identified so that appropriate treatment can be prescribed. Conservative measures, which include rest, cross-training, orthotic changes, and altering training methods, are often curative. Surgery is usually indicated only after conservative measures have been exhausted. Careful preoperative planning is needed to minimize dissection, thereby optimizing the chance of a return to the preinjury activity level. Preoperative counseling of the patient is also important, so that expectations about the outcome and the rehabilitation requirements are realistic.

                  • Subspecialty:
                  • Foot and Ankle

                  • Sports Medicine

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