JAAOS

JAAOS, Volume 3, No. 4


Ankle Pain in Children: Diagnostic Evaluation and Clinical Decision Making.

Ankle pain in children can be caused by traumatic injuries to bone, ligament, or tendon or by nontraumatic conditions, such as congenital and developmental anomalies, infections and other inflammatory disorders, neural compression, metabolic derangements, and neoplasia. Evaluation of children with this complaint should include a focused history and an anatomically oriented physical examination. Depending on the findings, further diagnostic workup and laboratory evaluation should be done. Appropriate treatment-whether casting, surgery, antibiotic therapy, or a combination thereof-can then be selected on a rational basis.

      • Subspecialty:
      • Trauma

      • Foot and Ankle

      • Pediatric Orthopaedics

      • Pain Management

    Femoral-Shaft Fractures in Children and Adolescents.

    Femoral-shaft fractures are frequent in children and adolescents. Fortunately, most unite rapidly without significant complications or sequelae. Treatment options include spica casting, traction, external fixation, compression plating, and flexible or locked intramedullary nailing, each of which has advantages and dis-advantages. Treatment is determined primarily on the basis of the age of the patient and the presence of associated injuries, but psychological, economic, and environmental factors also must be considered. The appropriate treatment can be determined only by careful consideration of all factors and close consultation with the family. Meticulous attention to technical details will help decrease the incidence of complications from both nonoperative and operative treatment.

        • Subspecialty:
        • Trauma

        • Pediatric Orthopaedics

      Internal Fixation of the Cervical Spine: Current Indications and Techniques.

      Numerous techniques for the internal fixation of the cervical spine have been developed in recent years. The indications for surgery must be strictly defined before the optimal type of implant can be selected on the basis of the advantages and potential risks. Wiring techniques are still commonly used for posterior stabilization. Anterior fusion can be accomplished without internal fixation in most cases. The halo vest is still widely used for the conservative management of cervical fractures and for postoperative external immobilization. Posteriorly, traditional wiring methods are still used, as well as newer techniques, such as C1-C2 screw fixation, occipitocervical plate fixation, and lateral-mass lower cervical plating. Anteriorly, meticulous Smith-Robinson surgical approach and grafting techniques are essential. Further studies are needed to define the exact indications for various new techniques, such as anterior odontoid screw fixation and anterior plating. The surgeon must choose an appropriate device on the basis of the mechanism of injury, the pathoanatomy of the lesion, and familiarity with the device, keeping in mind the goals of internal fixation-stabilization, reduction and maintenance of alignment, early rehabilitation, and perhaps enhancement of fusion and avoidance of the need to use an external halo vest.

          • Subspecialty:
          • Trauma

          • Spine

        Management of the Mangled Hand and Forearm.

        In this article the authors describe the methods and procedures that have been used to help patients regain hand and forearm function after mangling injuries. Assessment of the pathophysiologic condition, careful inventory of the injured structures, and early aggressive wound excision and reconstruction, followed by expert rehabilitation, are advocated. The importance of vascular restoration, stable skeletal fixation, and provision of adequate skin cover are stressed. In addition to describing their treatment approach, the authors emphasize the need for the surgeon to be well acquainted with each phase of the treatment process.

            • Subspecialty:
            • Trauma

            • Hand and Wrist

          Osteochondritis Dissecans of the Knee: Treatment of Juvenile and Adult Forms.

          Osteochondritis dissecans (OCD) and juvenile osteochondritis dissecans (JOCD) are distinct entities that require different management. Although both conditions result from stress fractures of the subchondral bone, JOCD has a much better prog-nosis; treated conservatively, 50% of cases will heal, probably providing a normal knee during adult life. In contrast, OCD often is followed by the early onset of degenerative arthritis. The treatment of JOCD and OCD, whether nonoperative or operative, should be based on the principles of fracture treatment. Unfortunately, surgical correction of either of these conditions is unlikely to succeed unless the joint surface is perfectly restored.

              • Subspecialty:
              • Trauma

              • Pediatric Orthopaedics

            The Diabetic Foot.

            Management of foot problems in the patient with diabetes mellitus requires attention to each system affected by the disease. Appropriate treatment of common clinical problems affecting the foot in diabetic patients, such as ulcerations and fractures, depends on a thorough understanding of the pathophysiology of the disease. Treatment of neuropathy is directed at pressure relief and prevention of deformity. Infection is addressed with antibiotics, debridement, and improvement of the vascularity and oxygenation of the tissues. Amputation should be viewed, not as evidence of treatment failure, but as a reconstructive procedure, the goal of which is to regain energy-efficient ambulation. The orthopaedic surgeon can play a critical role in the team approach to the care of the diabetic patient with foot problems.

                • Subspecialty:
                • Foot and Ankle

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