JAAOS

JAAOS, Volume 5, No. 4


Calcific Tendinopathy of the Rotator Cuff: Pathogenesis, Diagnosis, and Management.

Calcific tendinopathy, or calcifying tendinitis, is a disease characterized by multifocal, cell-mediated calcification of living tissue. After spontaneous disappearance of the calcific deposits or, less frequently, surgical removal, the tendon reconstitutes itself. Attention to the clinical presentation and the radiologic, morphologic, and gross characteristics of the calcium deposit will facilitate differentiation between the formative phase and the resorptive phase, which is of paramount importance in the management of this disease. Should conservative treatment fail, surgical removal may be indicated during the formative phase, but only under exceptional circumstances during the resorptive phase. Aspiration and lavage of the deposit should be performed only during the latter phase.

      • Subspecialty:
      • Sports Medicine

      • Shoulder and Elbow

    Compression Plating Versus Intramedullary Fixation of Humeral Shaft Fractures.

    Most humeral shaft fractures do not require surgery. When operative stabilization is indicated, the surgeon can choose between compression plating and intramedullary fixation. The results after compression plating have been shown to be predictable with respect to healing, alignment, and range of motion of the shoulder and elbow joints. Although complications are unusual with plate fixation, the procedure can require extensive dissection and operative time. Intramedullary fixation offers an alternative to plate fixation, with the principal advantage being a limited surgical dissection. This benefit must be balanced against the reportedly high rate of postoperative shoulder problems seen with antegrade nail placement. Unfortunately, few direct comparative studies have been done to evaluate the various techniques. The authors attempt to clarify and resolve these issues.

        • Subspecialty:
        • Trauma

        • Shoulder and Elbow

      Hindfoot Dislocations: When Are They Not Benign?

      Acute hindfoot dislocations are usually characterized by displacement of both the talocalcaneal and the talonavicular joints. Medial dislocations are more common than lateral ones. Closed reduction is usually obtained easily. When closed attempts fail, surgical exploration and removal of recognized obstacles to reduction are necessary. Associated open wounds necessitate aggressive operative management to prevent infection. Postreduction radiographs should be scrutinized for the presence of associated fractures that require fixation or surgical removal. A short-leg walking cast should be used for 3 to 6 weeks. In rare instances, the tibiotalar joint is also dislocated, which usually necessitates open reduction or, if the injury is open, extruded, and contaminated, talar excision. All hindfoot dislocations result in some stiffening of the hindfoot. Painful degenerative arthrosis sometimes develops after this injury. Factors that predispose to poor outcomes include high-energy mechanisms, the presence of open wounds and fractures, and lateral dislocations. Painful arthrosis that does not respond to conservative treatment can be treated with selective hindfoot arthrodesis.

          • Subspecialty:
          • Trauma

          • Foot and Ankle

        Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint.

        Injuries to the ulnar collateral ligament of the metacarpophalangeal (MCP) joint of the thumb are relatively common. When an incomplete rupture is present, valgus stress testing with the MCP joint positioned in extension reveals minimal or no instability (less than 30 degrees of laxity or less than 15 degrees more laxity than in the noninjured thumb). When a complete rupture is present, valgus stress testing with the MCP joint positioned in extension reveals marked laxity (more than 30 degrees or more than 15 degrees more laxity than in the noninjured thumb). In this instance, displacement of the ligament proximal and superficial to the adductor aponeurosis, which is often termed a Stener lesion, is likely. Partial ligament injuries in which the ligament is not displaced may be treated nonoperatively. When a Stener lesion is present, however, primary ligament healing cannot occur without operative management. Whether treatment should be operative or nonperative can generally be decided on the basis of the findings from the history, the radiographs, and the physical examination, which should include valgus stress testing.

            • Subspecialty:
            • Hand and Wrist

          Obstetric Brachial Plexus Injuries: Evaluation and Management.

          Most infants with brachial plexus birth palsy who show signs of recovery in the first 2 months of life will subsequently have normal function. However, infants who do not recover in the first 3 months of life have a considerable risk of long-term limited strength and range of motion. As the delay in recovery extends from 3 months to beyond 6 months, this risk increases pro-portionately. The presence of a total plexus lesion, a partial plexus lesion with loss at C5-C7, or Horner's syndrome carries a worse prognosis. Microsurgery is indicated for failure of return of function by 3 to 6 months. The exact timing of intervention is still open to debate. With microsurgical reconstruction, there is improvement in outcome in a high percentage of patients. However, the neural lesion is too severe and complex for present methods of reconstruction to restore normal function. Secondary correction of shoulder dysfunction with either latissimus dorsiteres major tendon transfer or humeral derotation osteotomy is clearly beneficial for patients with chronic brachial plexopathy, as is reconstruction of supination forearm contracture with biceps rerouting transfer and/or forearm osteotomy. Reconstruction of the hand is also indicated for the patient with chronic disability. All of these procedures improve, but do not completely normalize, function.

              • Subspecialty:
              • Pediatric Orthopaedics

            Odontoid Fractures: Evaluation and Management.

            Fractures of the odontoid process are uncommon injuries. Fracture displacement, compromised blood supply, comminution, and iatrogenic distraction have all been implicated in the reported high rates of nonunion. Plain radiography, polytomography, and computed tomography are all useful in delineating the fracture pattern. Magnetic resonance imaging has been recommended for evaluating associated ligamentous injuries and may be helpful in detecting occult cervical spine fractures. Type I fractures are avulsion fractures of the tip of the odontoid process. These rare injuries require only external immobilization with an orthosis if there is no associated ligamentous injury. Type II fractures occur at the junction of the odontoid process and the body of the axis. These are the most common odontoid fractures and are associated with a high incidence of nonunion. Nondisplaced fractures should be treated with halo immobilization for 8 to 12 weeks, with careful clinical and radiographic monitoring. Displaced fractures should be considered for operative treatment, either with atlantoaxial arthrodesis or anterior screw fixation. Type III fractures, which extend into the body of the axis through cancellous bone, are treated with closed reduction and halo immobilization.

                • Subspecialty:
                • Trauma

                • Spine

                • Basic Science

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