JAAOS

JAAOS, Volume 7, No. 3


Acute management of spinal cord injury.

Demographic trends in the occurrence of injury and improvements in the early management of spinal trauma are changing the long-term profile of patients with spinal cord injuries. More patients are surviving the initial injury, and proportionately fewer patients are sustaining complete injuries. While preventive efforts to reduce the overall incidence of spinal cord injury are important, a number of steps can be taken to minimize secondary injury once the initial trauma has occurred. Recent efforts have focused on understanding the biochemical basis of secondary injury and developing pharmacologic agents to intervene in the progression of neurologic deterioration. The Third National Acute Spinal Cord Injury Study investigators concluded that methylprednisolone improves neurologic recovery after acute spinal cord injury and recommended that patients who receive methylprednisolone within 3 hours of injury should be maintained on the treatment regimen for 24 hours. When methylprednisolone therapy is initiated 3 to 8 hours after injury, it should continue for 48 hours. In addition to the adoption of the guidelines of that study, rapid reduction and stabilization of injuries causing spinal cord compression are critical steps in optimizing patients' long-term neurologic and functional outcomes.

    • Keywords:
    • Chemoprevention|Disease Progression|Humans|Methylprednisolone|Nerve Regeneration|Neurologic Examination|Neuroprotective Agents|Spinal Cord|Spinal Cord Compression|Spinal Cord Injuries|Spinal Injuries|Survival Rate|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Spine

    • Basic Science

Approach to the polytraumatized patient with musculoskeletal injuries.

The management of the multiply injured patient is a challenge for even experienced clinicians. Because many community hospitals lack a dedicated trauma team, it is often the orthopaedic surgeon who will direct treatment. Therefore, the orthopaedic surgeon must have an understanding of established guidelines for the evaluation, resuscitation, and care of the severely injured patient. Initial evaluation encompasses assessment and intervention for airway, breathing, circulation, disability (neurologic injury), and environmental and exposure considerations. Resuscitation requires not only administration of fluids, blood, and blood products but also emergent management of pelvic trauma and stabilization of long-bone fractures. Judicious early use of anterior pelvic external fixation can be lifesaving in many cases. The secondary survey, which is often neglected, must incorporate a thorough physical evaluation. Although the method of fracture stabilization is still controversial, most clinicians agree that early fixation offers many benefits, including early mobilization, improved pulmonary toilet, decreased cardiovascular risk, and improved psychological well-being. Without an understanding of the complexities of the multiply injured patient, delays in the diagnosis and treatment of a patient's injuries are likely to adversely affect outcome.

    • Keywords:
    • Attitude to Health|Blood Circulation|Blood Transfusion|Early Ambulation|External Fixators|Fluid Therapy|Fracture Fixation|Fractures

    • Bone|Humans|Lung|Multiple Trauma|Musculoskeletal System|Neurologic Examination|Orthopedic Procedures|Patient Care Team|Pelvic Bones|Physical Examination|Respiration|Resuscitation|Risk Factors|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Basic Science

Distal biceps tendon injuries: diagnosis and management.

Rupture of the distal biceps tendon occurs most commonly in the dominant extremity of men between 40 and 60 years of age when an unexpected extension force is applied to the flexed arm. Although previously thought to be an uncommon injury, distal biceps tendon ruptures are being reported with increasing frequency. The rupture typically occurs at the tendon insertion into the radial tuberosity in an area of preexisting tendon degeneration. The diagnosis is made on the basis of a history of a painful, tearing sensation in the antecubital region. Physical examination demonstrates a palpable and visible deformity of the distal biceps muscle belly with weakness in flexion and supination. The ability to palpate the tendon in the antecubital fossa may indicate partial tearing of the biceps tendon. Plain radiographs may show hypertrophic bone formation at the radial tuberosity. Magnetic resonance imaging is generally not required to diagnose a complete rupture but may be useful in the case of a partial rupture. Early surgical reattachment to the radial tuberosity is recommended for optimal results. A modified two-incision technique is the most widely used method of repair, but anterior single-incision techniques may be equally effective provided the radial nerve is protected. The patient with a chronic rupture may benefit from surgical reattachment, but proximal retraction and scarring of the muscle belly can make tendon mobilization difficult, and inadequate length of the distal biceps tendon may necessitate tendon augmentation. Postoperative rehabilitation must emphasize protected return of motion for the first 8 weeks after repair. Formal strengthening may begin as early as 8 weeks, with a return to unrestricted activities, including lifting, by 5 months.

    • Keywords:
    • Activities of Daily Living|Adult|Arm Injuries|Biomechanics|Humans|Hyperostosis|Magnetic Resonance Imaging|Male|Middle Aged|Muscle Contraction|Muscle

    • Skeletal|Palpation|Physical Examination|Radius|Rupture|Sports|Supination|Tendon Injuries|Tendons

    • Subspecialty:
    • Trauma

    • Sports Medicine

    • Pain Management

Limb-length inequality: assessment and treatment options.

Assessment and treatment of limb-length inequality, particularly in the growing child, is a challenging task. Evaluation of the discrepancy requires an understanding of the significance of the disparity, as well as the natural history of the disorder, before formulation of a treatment plan. In the immature patient, consistent longitudinal data are essential to avoid pitfalls in the projection of ultimate length difference. Therapeutic options range from no treatment or use of a simple shoe lift to a surgical shortening or lengthening procedure. The current indication for lengthening is a disparity exceeding 5 to 6 cm. Epiphysiodesis or femoral shortening is useful for smaller discrepancies or for residual differences following a contralateral lengthening. Lengthening is done with a circular or cantilever external fixator, which may be combined with an intramedullary rod.

    • Keywords:
    • Age Determination by Skeleton|Bone Lengthening|Child|Epiphyses|External Fixators|Femur|Forecasting|Humans|Leg|Leg Length Inequality|Orthotic Devices|Patient Care Planning|Shoes

    • Subspecialty:
    • Pediatric Orthopaedics

Painful conditions of the acromioclavicular joint.

The acromioclavicular (AC) joint may be affected by a number of pathologic processes, most commonly osteoarthritis, posttraumatic arthritis, and distal clavicle osteolysis. The correct diagnosis of a problem can usually be deduced from a thorough history, physical examination, and radiologic evaluation. Asymptomatic AC joint degeneration is frequent and does not always correlate with the presence of symptoms. Selective lidocaine injection enhances diagnostic accuracy and may correlate with surgical outcome. Nonoperative treatment is helpful for most patients, although those with osteolysis may have to modify their activities. In appropriately selected patients, open or arthroscopic distal clavicle resection is necessary to relieve symptoms. Recent biomechanical and clinical data emphasize the importance of capsular preservation and minimization of bone resection; however, the optimal amount of distal clavicle resection remains elusive. Patients with AC joint instability have poor results after distal clavicle resection.

    • Keywords:
    • Acromioclavicular Joint|Anesthetics

    • Local|Arthritis|Arthroscopy|Biomechanics|Clavicle|Diagnosis

    • Differential|Endoscopy|Humans|Joint Capsule|Joint Diseases|Joint Instability|Lidocaine|Medical History Taking|Osteoarthritis|Osteolysis|Physical Examination|Treatment Outcome

    • Subspecialty:
    • Shoulder and Elbow

    • Pain Management

    • Basic Science

Revision anterior cruciate ligament reconstruction surgery.

Revision anterior cruciate ligament (ACL) reconstruction is indicated for selected patients with recurrent instability after a failed primary procedure. The cause of the failure must be carefully identified to avoid pitfalls that may cause the revision to fail as well. Associated instability patterns must be recognized and corrected to achieve a successful result. The choice of graft, the problem of retained hardware, and tunnel placement are the major challenges of revision ACL reconstruction. The patient must have reasonable expectations and understand that the primary goal of surgery is restoration of the ability to perform activities of daily living, rather than a return to competitive athletics. The results of revision ACL reconstructions are not as good as those after primary reconstructions; however, the procedure appears to be beneficial for most patients.

    • Keywords:
    • Activities of Daily Living|Anterior Cruciate Ligament|Humans|Joint Instability|Knee Joint|Orthopedic Fixation Devices|Patient Education as Topic|Reconstructive Surgical Procedures|Recurrence|Reoperation|Sports|Treatment Failure|Treatment Outcome

    • Subspecialty:
    • Sports Medicine

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