JAAOS

JAAOS, Volume 8, No. 6


Displaced three- and four-part proximal humerus fractures: evaluation and management.

Three- and four-part fractures are the most severe injuries in the spectrum of fractures of the proximal humerus. Despite the shortcomings of the currently available imaging techniques, fracture displacement remains an important principle in guiding management. As a result, increasing emphasis has been placed on the use of Neer's criteria in intraoperative decision making. Patients with four-part fractures with valgus impaction of the head fragment should be treated with limited open reduction and minimal internal fixation, as the blood supply to the humeral head is better preserved than with other fracture patterns and the potential for osteonecrosis is less. In the case of displaced three- and four-part fractures, the physiologic age and bone quality also help guide treatment selection. In young patients with good bone quality, attempts to preserve the humeral head by meticulous handling of soft tissues and the use of low-profile implants to secure fracture fragments is recommended. Vertical fixation alone with Rush rods in patients with poor bone quality and in those with four-part fractures is no longer considered adequate and should not be used. For selected patients with three-part fractures and satisfactory bone quality, fixation with Ender rods and tension-band wiring may be appropriate. Elderly patients and those with poor bone quality have a greater risk of loss of reduction after open reduction and internal fixation, and the current consensus is that early hemiarthroplasty is the appropriate treatment. Late reconstruction necessitated by malunion and soft-tissue contracture is technically difficult, and the outcome is less favorable. The outcome of treatment of three- and four-part fractures is dependent on the surgeon's ability to analyze the fracture pattern and execute appropriate techniques to restore anatomy and function. The use of cement for prosthetic fixation and rigorous attention to tuberosity stabilization and anatomic reduction are two factors that will optimize outcome. Adequate pain relief after hemiarthroplasty has been consistently demonstrated, but return of motion and function is less predictable.

    • Keywords:
    • Arthroplasty

    • Replacement|Fracture Fixation

    • Internal|Humans|Shoulder Fractures|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

    • Adult Reconstruction

    • Pain Management

Fractures of the proximal interphalangeal joint.

Fractures of the proximal interphalangeal joint constitute a broad spectrum of injuries. An understanding of the anatomy, the potential for joint instability, and the treatment options is essential to management of these fractures. Commonly observed fracture patterns involve one or both condyles of the proximal phalanx or the base of the middle phalanx. Fractures of the middle phalanx may involve the palmar lip or the dorsal lip or may be a "pilon" type of injury involving both the palmar and the dorsal lip with extensive intra-articular comminution. Intra-articular injuries may lead to joint subluxation or dislocation and must be identified in a timely manner to limit loss of motion, degenerative changes, and impaired function. These injuries range from those requiring minimal intervention to obtain an excellent outcome to those that are challenging to the most experienced surgeon. The treatment options include extension-block splinting, percutaneous pinning, traction, external fixation, open reduction and internal fixation, and volar-plate arthroplasty. Prompt recognition of the complexity of the injury and appropriate management are essential for an optimal functional outcome.

    • Keywords:
    • Biomechanics|Exercise Therapy|Finger Injuries|Fractures

    • Bone|Humans|Immobilization|Range of Motion

    • Articular|Traction

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Healing and repair of ligament injuries in the knee.

Although methods of treating ligamentous injuries have continually improved, many questions remain about enhancing the rate, quality, and completeness of ligament healing. It is known that the ability of a torn ligament to heal depends on a variety of factors, including anatomic location, presence of associated injuries, and selected treatment modality. A grade III injury of the medial collateral ligament (MCL) of the knee usually heals spontaneously. Surgical repair followed by immobilization of an isolated MCL tear does not enhance the healing process. In contrast, tears of the anterior cruciate ligament (ACL) and the posterior cruciate ligament often require surgical reconstruction. The MCL component of a combined ACL-MCL injury has a worse prognosis than an isolated MCL injury. The results of animal studies suggest that nonoperative treatment of an MCL injury is effective if combined with operative reconstruction of the ACL. Experimentation using animal models has helped to define the effects of ligament location, associated injuries, intrinsic factors, surgical repair, reconstruction, and exercise on ligament healing. New techniques utilizing growth factors and cell and gene therapies may offer the potential to enhance the rate and quality of healing of ligaments of the knee, as well as other ligaments in the body.

    • Keywords:
    • Animals|Biomechanics|Exercise Therapy|Knee Injuries|Ligaments

    • Articular|Prognosis|Wound Healing

    • Subspecialty:
    • Sports Medicine

High-risk stress fractures: evaluation and treatment.

Stress fractures are common overuse injuries seen in athletes and military recruits. The pathogenesis is multifactorial and usually involves repetitive submaximal stresses. Intrinsic factors, such as hormonal imbalances, may also contribute to the onset of stress fractures, especially in women. The classic presentation is a patient who experiences the insidious onset of pain after an abrupt increase in the duration or intensity of exercise. The diagnosis is primarily clinical, but imaging modalities such as plain radiography, scintigraphy, computed tomography, and magnetic resonance imaging may provide confirmation. Most stress fractures are uncomplicated and can be managed by rest and restriction from the precipitating activity. A subset of stress fractures can present a high risk for progression to complete fracture, delayed union, or nonunion. Specific sites for this type of stress fracture are the femoral neck (tension side), the patella, the anterior cortex of the tibia, the medial malleolus, the talus, the tarsal navicular, the fifth metatarsal, and the great toe sesamoids. Tensile forces and the relative avascularity at the site of a stress-induced fracture often lead to poor healing. Therefore, high-risk stress fractures require aggressive treatment.

    • Keywords:
    • Algorithms|Biomechanics|Femoral Neck Fractures|Fractures

    • Stress|Humans|Metatarsus|Patella|Tibia

    • Subspecialty:
    • Trauma

Perspectives on modern orthopaedics: use of Adcon-L for epidural scar prevention.

Adcon-L is a biodegradable gel matrix that was recently approved by the Food and Drug Administration for use during single-level posterior lumbar laminectomy or laminotomy procedures. Experimental and clinical studies have suggested that the use of this product will decrease postoperative epidural scarring. However, the relationship between epidural fibrosis and patient outcome remains unclear. If the treating surgeon is of the opinion that there is a need to reduce epidural scar, the use of this product appears worthwhile. However, further studies are needed to evaluate clinical outcome and justify the use of this product on a routine basis.

    • Keywords:
    • Animals|Cicatrix|Gels|Humans|Laminectomy|Organic Chemicals

    • Subspecialty:
    • General Orthopaedics

Reconstruction of the failed femoral component and proximal femoral bone loss in revision hip surgery.

Advances in implant technology and surgical techniques have greatly improved the results of femoral stem revision in total hip arthroplasty. The 10-year results obtained with extensively coated noncemented revision stems parallel those obtained with cemented stems revised by using contemporary techniques. Proximal femoral bone loss is an important consideration when planning and performing revision arthroplasty. Proximal femoral bone defects can be managed with either metal or bone. Insignificant defects can be reconstructed by using primary hip arthroplasty techniques. Proximal femoral replacement prostheses are best restricted to sedentary elderly patients. Cortical strut grafts can be used reliably to reconstruct noncircumferential segmental defects. Calcar allografts are associated with unacceptably high rates of resorption. Proximal femoral allografts with either noncemented or cemented long-stem prostheses have the potential advantage of biologic soft-tissue attachment and restoration of bone stock. Impaction allografting with cement is indicated for cavitary defects and may also restore bone stock.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Cementation|Femur|Humans|Osteolysis|Prosthesis Failure|Reconstructive Surgical Procedures|Reoperation|Treatment Outcome

    • Subspecialty:
    • Adult Reconstruction

    • Basic Science

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