JAAOS

JAAOS, Volume 8, No. 4


Acute fractures of the scaphoid.

Nondisplaced fractures of the scaphoid heal with cast immobilization in most cases, but operative treatment is being offered with greater frequency to active patients as an approach to reduce the period of cast immobilization. Computed tomography is more useful for evaluating displacement than standard radiography. Displaced fractures are at greater risk for nonunion and malunion-both of which have been associated with the development of radiocarpal arthritis in long-term studies--and should therefore be treated operatively. Surgical treatment is also recommended for complex fractures (open fractures, perilunate fracture-dislocations, and scaphoid fractures associated with fracture of the distal radius), very proximal fractures, and fractures for which the diagnosis and treatment have been delayed. Operative treatment of fractures of the scaphoid has been simplified by the development of cannulated screws. Internal fixation of fractures of the scaphoid may offer some advantages, including earlier return to athletics or manual labor.

    • Keywords:
    • Acute Disease|Carpal Bones|Casts

    • Surgical|Fracture Fixation

    • Internal|Fracture Healing|Fractures

    • Bone|Fractures

    • Malunited|Fractures

    • Ununited|Humans|Risk Factors|Tomography

    • X-Ray Computed|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Complications after treatment of tibial pilon fractures: prevention and management strategies.

Complications after treatment of tibial pilon fractures can occur intraoperatively or in the early or late postoperative period. Perioperative complications include malreduction, inadequate fixation, and intra-articular penetration of hardware, all of which may be minimized by preoperative planning and meticulous operative technique. Wound complications can lead to deep infection, with potentially catastrophic consequences. The incidence of wound complications may be lessened by delaying surgery 5 to 14 days, until the posttraumatic swelling has subsided. Temporary fixation with a medial spanning external fixator is recommended if definitive internal fixation is delayed. Fracture blisters should be left undisturbed until the time of surgery. Incisions through blood-filled blisters should be avoided whenever possible. Limited incisions to achieve reduction and fixation should be made directly over fracture sites, to minimize soft-tissue stripping. An indirect reduction technique involving the use of ligamentotaxis and low-profile small-fragment implants that minimize tension on the incision should be used. Late complications, such as stiffness and posttraumatic arthritis, correlate with the severity of the initial injury and the accuracy of reduction. Loss of ankle motion can be minimized by early range-of-motion exercise after stable fixation has been achieved. Posttraumatic ankle arthrosis should be initially treated with anti-inflammatory medication, activity modification, and walking aids. Symptomatic patients often require an ankle arthrodesis.

    • Keywords:
    • Arthritis|Biomechanics|Fracture Fixation|Fractures

    • Malunited|Fractures

    • Ununited|Humans|Patient Care Planning|Postoperative Complications|Range of Motion

    • Articular|Tibial Fractures|Time Factors|Treatment Outcome|Weight-Bearing|Wound Infection

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Development dysplasia of the hip from birth to six months.

The term "developmental dysplasia or dislocation of the hip" (DDH) refers to the complete spectrum of abnormalities involving the growing hip, with varied expression from dysplasia to subluxation to dislocation of the hip joint. Unlike the term "congenital dysplasia or dislocation of the hip," DDH is not restricted to congenital problems but also includes developmental problems of the hip. It is important to diagnose these conditions early to improve the results of treat- ment, decrease the risk of complications, and favorably alter the natural history. Careful history taking and physical examination in conjunction with advances in imaging techniques, such as ultrasonography, have increased the ability to diagnose and manage DDH. Use of the Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If stable reduction cannot be obtained after 2 weeks of treatment with the Pavlik harness, alternative treatment, such as examination of the hip under general anesthesia with possible closed reduction, is indicated. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step. Toward the end of the first year of life, the toddlerTs ability to stand and bear weight on the lower extremities, as well as the progressive adaptations and soft- tissue contractures associated with the dislocated hip, preclude use of the Pavlik harness.

    • Keywords:
    • Algorithms|Anthropometry|Casts

    • Surgical|Decision Trees|Hip Dislocation

    • Congenital|Humans|Infant|Infant

    • Newborn|Manipulation

    • Orthopedic|Medical History Taking|Neonatal Screening|Physical Examination|Risk Factors|Splints|Terminology as Topic|Treatment Outcome|Walking|Weight-Bearing

    • Subspecialty:
    • Pediatric Orthopaedics

Olecranon fractures: treatment options.

Fractures of the olecranon process of the ulna typically occur as a result of a motor-vehicle or motorcycle accident, a fall, or assault. Nondisplaced fractures can be treated with a short period of immobilization followed by gradually increasing range of motion. Open reduction and internal fixation is the standard treatment for displaced intra-articular fractures. Stable internal fixation with figure-of-eight tension-band wire fixation for simple transverse fractures allows early motion to minimize stiffness. Use of two knots produces symmetric tension at the fracture site and provides more rigid fixation than a single knot. Care should be taken to ensure that the tension-band wire and the proximal ends of the Kirschner wires are positioned deep to the triceps fibers to prevent wire migration. If the anterior cortex is engaged, overpenetration of the wires into the soft tissues should be avoided. Plate fixation is appropriate for severely comminuted fractures, distal fractures involving the coronoid process, oblique fractures distal to the midpoint of the trochlear notch, Monteggia fracture-dislocations of the elbow, and nonunions. For comminuted fractures and nonunions, a dorsally applied limited-contact dynamic-compression plate with supplemental bone graft should be utilized to support comminuted depressed articular fragments. A one-third tubular hook-plate can be used for fractures with a small proximal fragment for which additional fixation of the olecranon tip is desired. Fragment excision and triceps advancement is appropriate in selected cases in which open reduction seems unlikely to be successful, such as in osteoporotic elderly patients with severely comminuted fractures.

    • Keywords:
    • Biomechanics|Bone Plates|Bone Screws|Casts

    • Surgical|Elbow Joint|Fracture Fixation

    • Internal|Fracture Healing|Fractures

    • Bone|Humans|Patient Selection|Postoperative Care|Range of Motion

    • Articular|Risk Factors|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

    • Basic Science

Percutaneous plating in the lower extremity.

Since the late 1950s, open reduction and internal fixation has been advocated to restore bone anatomy and enable early mobilization. This approach often necessitated extensive dissection and tissue devitalization, creating an environment less favorable for fracture union and more prone to bone infection. As a result, other methods, such as intramedullary nailing, have become the standard treatment for most diaphyseal fractures of the femur and tibia. However, internal fixation with plates and screws remains the treatment of choice for most periarticular fractures and other complex fractures inadequately stabilized by intramedullary nailing. Recently, more "biologic" methods of reduction involving the use of indirect techniques and new plate designs have been developed in an attempt to preserve the blood supply to the injured bone, improve the rate of fracture healing, decrease the need for bone grafting, and lower the incidence of infection and other complications. Percutaneous plating appears to be the next step in the evolution of biologic plating. With these techniques, the fracture is reduced indirectly, and plates are placed into submuscular or subcutaneous tunnels through limited skin incisions. This may result in less surgical trauma to tissues and further improvements in clinical results compared with current methods of plate insertion.

    • Keywords:
    • Bone Plates|Femoral Fractures|Fracture Fixation

    • Internal|Fracture Healing|Humans|Prosthesis Design|Surgical Procedures

    • Minimally Invasive|Tibial Fractures

    • Subspecialty:
    • Trauma

    • Basic Science

Peripheral nerve injury and repair.

Peripheral nerve injuries are common, and there is no easily available formula for successful treatment. Incomplete injuries are most frequent. Seddon classified nerve injuries into three categories: neurapraxia, axonotmesis, and neurotmesis. After complete axonal transection, the neuron undergoes a number of degenerative processes, followed by attempts at regeneration. A distal growth cone seeks out connections with the degenerated distal fiber. The current surgical standard is epineurial repair with nylon suture. To span gaps that primary repair cannot bridge without excessive tension, nerve-cable interfascicular auto-grafts are employed. Unfortunately, results of nerve repair to date have been no better than fair, with only 50% of patients regaining useful function. There is much ongoing research regarding pharmacologic agents, immune system modulators, enhancing factors, and entubulation chambers. Clinically applicable developments from these investigations will continue to improve the results of treatment of nerve injuries.

    • Keywords:
    • Humans|Injury Severity Score|Nerve Regeneration|Nerve Transfer|Peripheral Nerves|Recovery of Function|Suture Techniques|Transplantation

    • Autologous|Transplantation

    • Homologous|Treatment Outcome

    • Subspecialty:
    • Spine

    • General Orthopaedics

Unicameral bone cysts.

Unicameral, or solitary, bone cysts are unusual tumors seen in the ends of long bones in skeletally immature persons. The etiology of these lesions is poorly understood. Various hypotheses have included dysplastic processes, synovial cysts, and abnormalities in the local circulation. Most patients present with a nondisplaced pathologic fracture, but occasionally cysts are found incidentally. Plain radiographs typically show a symmetric lesion with cortical thinning and expansion of the cortical boundaries. Once diagnosed, unicameral bone cysts continue to be a treatment dilemma. Traditional methods, such as prednisolone therapy, usually involve multiple anesthetics and injections and are associated with high recurrence rates. Major surgical procedures, such as wide exposure, curettage, and bone grafting, may be somewhat more effective, but still carry with them significant morbidity and recurrence rates. Newer techniques involving percutaneous grafting with allograft or bone substitutes or a combination of the two are promising in light of their low complication rate and lower reoperation rate.

    • Keywords:
    • Anti-Inflammatory Agents|Bone Cysts|Bone Substitutes|Bone Transplantation|Curettage|Diagnosis

    • Differential|Fractures

    • Spontaneous|Humans|Morbidity|Osteotomy|Prednisolone|Prognosis|Recurrence|Treatment Outcome

    • Subspecialty:
    • Sports Medicine

    • Musculoskeletal Oncology

Advertisements

Advertisement