JAAOS

JAAOS, Volume 5, No. 1


Acromioclavicular Joint Injuries and Distal Clavicle Fractures.

The acromioclavicular joint is commonly affected by traumatic and degenerative conditions. Most injuries are due to direct trauma, such as a fall on the shoulder. Six types of acromioclavicular sprains and three types of distal clavicle fractures have been described in adults. Although there is general agreement on treatment of type I, II, IV, V, and VI acromioclavicular injuries, the treatment of type III injuries remains controversial. Studies have shown no distinct advantage for surgical reconstruction over nonoperative treatment. Because type II distal clavicle fractures are prone to nonunion, operative fixation may be advisable to avoid this complication.

      • Subspecialty:
      • Trauma

      • Shoulder and Elbow

      • Basic Science

    Displaced Fractures of the Radial Head: Internal Fixation or Excision?

    Displaced fractures of the radial head in the young active patient should no longer be routinely treated with excision of the radial head. Better techniques of imaging, surgical exposure, and implant placement have improved the likelihood of preserving the head. Associated injuries may make preservation of the radial head important for both acute and long-term stability. In patients with suspected injury to the interosseous ligament of the forearm, saving the radial head may prevent pathologic proximal migration. Rigid internal fixation, permitting early mobilization, can be applied to the radial head and neck in a "safe zone" that does not impede motion. Radial-head excision should be performed in patients with grossly comminuted fractures and in those with low demand on their upper extremities.

        • Subspecialty:
        • Trauma

        • Hand and Wrist

      Hip Dislocation: Current Treatment Regimens.

      Dislocation of the hip occurs only with high-energy trauma, and concomitant injuries are common. Early diagnosis and institution of treatment are necessary to obtain the best possible results. Treatment protocols include emergent reduction of the femoral head to reestablish perfusion, postreduction radiography and computed tomography to look for associated fractures and to judge the concentricity of the reduction, stability testing, and early mobilization. Open reduction may be required if a concentric reduction cannot be obtained in a closed manner. Despite appropriate management, posttraumatic arthritis and avascular necrosis may occur, with reported rates as high as 15% to 30%. Patients who sustain a hip dislocation should be made aware of these potential complications at the time of initial treatment.

          • Subspecialty:
          • Trauma

        Patellofemoral Instability: Evaluation and Management.

        Patellofemoral disorders are a common cause of knee pain and disability. A thorough history and a careful physical examination are essential to accurate diagnosis, and imaging modalities play an important role. Magnetic resonance imaging can provide information on malalignment and soft-tissue injuries. Although there is a continuum of diagnoses, most patellofemoral disorders can be divided into three distinct categories: soft-tissue abnormalities, patellar instability due to subluxation and dislocation, and patellofemoral arthritis. Many patellofemoral disorders respond to nonoperative therapy. When surgical intervention is necessary, patellar tilt can be successfully treated by a lateral release. Lateral patellar subluxation associated with malalignment can be corrected by a distal realignment procedure such as the anteromedial tibial tubercle transfer. Repair of the medial patellofemoral ligament in cases of patellar dislocation has considerably lowered the incidence of recurrent instability. Although no ideal treatment exists for patellofemoral arthritis, mechanical symptoms may be alleviated by arthroscopic debridement of delamination lesions. Articular cartilage-wear disorders may be stabilized by addressing the primary causative disorder.

            • Subspecialty:
            • Sports Medicine

            • Pain Management

          Soft-Tissue Injuries Associated With High-Energy Extremity Trauma: Principles of Management.

          The management of high-energy extremity trauma has evolved over the past several decades, and appropriate treatment of associated soft-tissue injuries has proved to be an important factor in achieving a satisfactory outcome. Early evaluation of the severely injured extremity is crucial. Severe closed injuries require serial observation of the soft tissues and early skeletal stabilization. Open injuries require early aggressive debridement of the soft tissues followed by skeletal stabilization. Temporary wound dressings should remain in place until definitive soft-tissue coverage has been obtained. Definitive soft-tissue closure will be expedited by serial debridements performed every 48 to 72 hours in a sterile environment. Skeletal union is facilitated by early bone grafting and/or modification of the stabilizing device. Aggressive rehabilitation, includ-ing early social reintegration, are crucial for a good functional outcome. Adherence to protocols is especially beneficial in the management of salvageable severely injured extremities.

              • Subspecialty:
              • Trauma

              • Basic Science

            Supracondylar Fractures of the Humerus in Children.

            The treatment of type II and type III supracondylar fractures of the humerus in children with closed reduction and percutaneous pinning has dramatically lowered the rate of complications from this injury. The incidence rates of malunion (cubitus varus) and compartment syndrome have both decreased. Nerve injury accompanying this type of fracture (prevalence, 5% to 19%) is usually a neurapraxia, which should be managed conservatively. Vascular insufficiency at presentation (prevalence, 5% to 17%) should be managed initially by rapid closed reduction and pinning without arteriography. Persistent vascular insufficiency necessitates exploration and vascular reconstruction.

                • Subspecialty:
                • Pediatric Orthopaedics

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