JAAOS

JAAOS, Volume 4, No. 5


Acute and Chronic Traumatic Injuries of the Sternoclavicular Joint.

Acute and chronic traumatic injuries of the sternoclavicular joint require accurate diagnosis and management if complications are to be avoided. Sternoclavicular subluxation or dislocation, medial clavicle physeal injuries, and degenerative arthritis are the most frequently diagnosed of these relatively uncommon injuries. The medial clavicular epiphysis does not ossify until the 18th to 20th year. Knowledge of its developmental anatomy is essential because most physeal injuries will heal with time without surgical intervention. In contrast, posterior dislocation of the sternoclavicular joint requires prompt closed or open reduction, as posterior displacement of the medial clavicle has been associated with numerous complications, including respiratory distress, venous congestion or arterial insufficiency, brachial plexus compression, and myocardial conduction abnormalities. A myriad of procedures have been recommended for repair or reconstruction of the sternoclavicular joint. On the basis of the authors' experience and review of the literature, they advocate surgical resection of the medial clavicle, with maintenance, repair, or reconstruction of the costoclavicular ligaments, when surgery is indicated. Metallic-pin fixation of the joint should be avoided, as Steinmann pins, Kirschner wires, threaded pins with bent ends, and Hagie pins have all been reported to migrate and cause serious complications, including death.

      • Subspecialty:
      • Trauma

      • Shoulder and Elbow

    Lumbar Spine Imaging: Role in Clinical Decision Making.

    Imaging studies are an integral component of the evaluation of the lumbar spine. For each study there is a specific role, an appropriate indication, and a correct time for utilization during the course of a patient's illness. The physician must know the specificity and sensitivity of each test, as well as the prevalence of abnormal findings in asymptomatic persons, to properly order and interpret the results of the studies. Many errors in decision making arise, not from misinterpretation of what is seen on imaging studies, but rather from misuse of imaging information in the clinical decision making process. Because all neurodiagnostic imaging modalities reveal abnormalities in at least a third of asymptomatic persons, the use of these tests for general screening is dangerous. The challenge for the future is to be able to better correlate what is seen on imaging studies with the patient's symptoms. Obtaining these expensive studies too early in the treatment of self-limited disorders is costly and often misleading for both the physician and the patient. The authors outline an approach to the judicious timing of imaging studies and discuss pitfalls in their interpretation in the evaluation of degenerative diseases of the lumbar spine.

        • Subspecialty:
        • Spine

      Meniscal Injuries in Children and Adolescents: Diagnosis and Management.

      Isolated meniscal injuries are uncommon in children under the age of 14, but the frequency increases thereafter. Meniscal tears in children are frequently associated with congenital meniscal abnormalities, while those in adolescents are often associated with ligamentous injuries of the knee. The combination of recurrent and often dramatic popping and intermittent episodes of locking has been termed the "snapping knee syndrome." This symptom complex is almost invariably associated with a discoid meniscus. Although double-contrast arthrography has proved to be a reliable diagnostic technique, magnetic resonance imaging is now the modality of choice. Treatment options for meniscal injuries in young patients should reflect a preference for repair over excision. The long-term clinical results of total meniscectomy in children have demonstrated a high incidence of degenerative joint disease. Partial excision may provide better results. The efficacy of meniscus transplantation in the skeletally immature knee, although attractive, is as yet unproved and is therefore not an acceptable treatment option.

          • Subspecialty:
          • Sports Medicine

          • Pediatric Orthopaedics

        Tibial Nonunion: Treatment Alternatives.

        Because the spectrum of injuries to the tibia is so great, no single method of treatment is applicable to all nonunions. Therefore, it is important for surgeons who treat tibial nonunions to be skilled in several different methods of treatment. In patients with significant deformities, electrical stimulation, isolated fibular osteotomy, and bone grafts alone are unsatisfactory treatment options. In aseptic nonunions, the use of intramedullary nailing or compression plating appears to have many advantages. In previously closed and selected grade I and grade II open fractures, reamed intramedullary nailing is a safe and effective method of treatment. Because of the risk of infection, reamed nailing is not recommended after external fixation of open fractures. In these cases as well as others, the authors prefer plate osteosynthesis. With few exceptions, the plate should be placed, under tension, on the convex side of the tibia. Used in this fashion, the plate can assist in correction of any deformity and can also provide stable internal fixation. Half-pin external fixation is used primarily in the management of infected fractures. Ilizarov and other small-wire circular fixators have proved effective in treating complex-composite deformities associated with sepsis, bone loss, shortening, angulation, or malrotation. Amputation may be warranted if a functional limb cannot be achieved.

            • Subspecialty:
            • Trauma

          Transmission of Human Immunodeficiency Virus Infection in the Surgical Setting.

          The emergence of the human immunodeficiency virus (HIV) has highlighted the need for orthopaedic surgeons to understand the epidemiology of percutaneous injuries and other blood exposures in the surgical setting. The American Academy of Orthopaedic Surgeons and the Centers for Disease Control and Prevention have worked to increase understanding and prevent transmission of blood-borne viral diseases in orthopaedic surgery. This article addresses the risk of HIV transmission in the surgical setting, with a focus on surveillance efforts to monitor the extent of occupational HIV infection, specific risk factors, and postexposure management. Health-care worker-to-patient transmission and patient-to-patient transmission are also addressed.

              • Subspecialty:
              • Clinical Practice Improvement

              • Basic Science

            Trochanteric Osteotomy for Total Hip Arthroplasty: Six Variations and Indications for Their Use.

            Trochanteric osteotomy of the femur in total hip replacement used to be a simple, stereotyped technique and was declining in frequency of use. Many variations in the technique have evolved recently, including the trochanteric slide and the extended trochanteric osteotomy, which have increased the flexibility and utility of trochanteric osteotomy and the frequency of its application. The authors describe six trochanteric osteotomies and discuss the indications for their use.

                • Subspecialty:
                • Adult Reconstruction

                • Basic Science

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