JAAOS

JAAOS, Volume 4, No. 4


Acute Compartment Syndrome: Update on Diagnosis and Treatment.

Acute compartment syndrome can have disastrous consequences. Because unusual pain may be the only symptom of an impending problem, a high index of suspicion, accurate evaluation, and prophylactic treatment will allow the physician to intervene in a timely manner and prevent irreversible damage. Muscles tolerate 4 hours of ischemia well, but by 6 hours the result is uncertain; after 8 hours, the damage is irreversible. Ischemic injury begins when tissue pressure is 10 to 20 mm Hg below diastolic pressure. Therefore, fasciotomy generally should be done when tissue pressure rises past 20 mm Hg below diastolic pressure.

      • Subspecialty:
      • Trauma

      • Sports Medicine

    Hand Infections: Treatment Recommendations for Specific Types.

    Hand infections can be associated with considerable morbidity. Expeditious treatment is needed to minimize permanent dysfunction, loss of work, and medical cost. Hand infections can affect the skin, subcutaneous tissues, fascia, subfascial and synovial spaces, joints, and bone. Pathogens include a variety of bacteria, viruses, yeasts, fungi, and mycoplasmata. Management frequently involves rest, elevation, incision and drainage, and appropriate antibiotic therapy. The orthopaedic surgeon must be knowledgeable about the pertinent anatomy and how this influences the behavior of specific types of infections, the role of immunocompromise, and the importance of early mobilization.

        • Subspecialty:
        • Hand and Wrist

      Isthmic Spondylolisthesis in the Adult.

      Isthmic spondylolisthesis is a common condition and is frequently identified in the adult patient with low back pain. Although the natural history of this condition is not well defined, it is a common indication for nonoperative and operative treatment. The authors outline a systematic approach to the evaluation of the adult patient with isthmic spondylolisthesis. If radiologic studies are required, magnetic resonance imaging has improved the visualization of nerve-root compression in the neural foramen and is now widely used. Nonoperative treatment is the preferred approach in most symptomatic patients and is successful in as many as 60%. If nonoperative treatment fails, surgery may be recommended. Arthrodesis continues to be the mainstay of surgical treatment. Nerve-root decompression can be used in selected patients with radiculopathy. Although the Food and Drug Administration still considers the use of pedicle-screw instrumentation investigational or experimental, it has gained wide acceptance as an adjunct to fusion in the adult. It is important to note, however, that such use has not yet been proved safe and effective. Reduction of the spondylolisthetic segment has increased in acceptance for a small subset of patients with defined indications but carries a significant risk of complications.

          • Subspecialty:
          • Spine

        Lateral Meniscal Variants: Evaluation and Treatment.

        The normal lateral meniscus is morphologically more variable than the medial meniscus. The abnormal lateral meniscus also varies with respect to size, shape, and stability. Variations can occur in patients of all ages. The underlying causes of lateral meniscal abnormalities are multifactorial. The spectrum of abnormalities includes the most common variant, discoid lateral meniscus, as well as less common conditions, such as a lateral meniscal variant with absence of the posterior coronary ligament. Treatment should be based on the severity of symptoms and the type of pathologic lesion.

            • Subspecialty:
            • Sports Medicine

            • Basic Science

          Stable Slipped Capital Femoral Epiphysis: Evaluation and Management.

          Slipped capital femoral epiphysis (SCFE) has been classified traditionally on the basis of the duration of symptoms, but it has recently been recognized that this classification system may be misleading. It has instead been recommended that slips be classified on the basis of the presence or absence of gross instability between the epiphysis and the metaphysis. An adolescent with chronic SCFE has had symptoms for more than 3 weeks and does not have physeal instability. The first priority of treatment of stable chronic SCFE is to avoid the complications of avascular necrosis and chondrolysis while securing the epiphysis from further slippage. The treatment of choice for stable chronic SCFE is stabilization in situ, which can be most easily achieved with single-screw fixation. Primary realignment procedures, such as osteotomies, are not recommended.

              • Subspecialty:
              • Pediatric Orthopaedics

            The Mangled Extremity: When Should It Be Amputated?

            Amputation of a mangled extremity is repugnant to the patient and the surgeon. However, prolonged unsuccessful attempts at salvage are costly, highly morbid, and sometimes lethal. Much discussion has taken place regarding which criteria predict successful salvage, and predictive indices have been proposed in an attempt to identify limbs for which attempted salvage is unlikely to succeed. The Mangled Extremity Severity Score, or MESS, system is the most thoroughly validated of the various classification systems, but at present there is no predictive scale that can be used with confidence to determine whether to amputate or attempt to salvage a mangled lower extremity. Therefore, these systems should serve only as guides to supplement the surgeon's clinical judgment and experience. Although salvage for severe injuries below the knee can be difficult and the functional outcome unpredictable, prosthetic function after transtibial amputation is generally good. Conversely, prosthetic function after transfemoral or transradial amputation is often poor, while salvage of some useful function for injuries above the knee is often successful. When limb loss is inevitable, immediate amputation is desirable. If obvious criteria for primary amputation are not met, however, it is reasonable to consider an initial salvage attempt, observation, and subsequent early secondary amputation.

                • Subspecialty:
                • Trauma

                • Foot and Ankle

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