JAAOS, Volume 9, No. 4

"Floating knee" injuries: ipsilateral fractures of the femur and tibia.

Ipsilateral fractures of the femur and tibia have been called "floating knee" injuries and may include combinations of diaphyseal, metaphyseal, and intra-articular fractures. These are often high-energy injuries and most frequently occur in the polytrauma patient. Many of these fractures are open, with associated vascular injuries. Surgical stabilization of both fractures and early mobilization of the patient and the extremity produce the best clinical outcomes. The use of a radiolucent operating room table and the introduction of retrograde intramedullary fixation of femoral fractures have facilitated surgical stabilization of some floating-knee fracture patterns. Although treatment planning for each fracture in the extremity should be considered individually to achieve the optimal result, the effect of that decision must be considered in light of the overall injury status of the entire extremity. Collateral ligament and meniscal injuries may also be associated with this fracture complex. Complications (such as compartment syndrome, loss of knee motion, failure to diagnose knee ligament injury, and the need for amputation) are not infrequent. Better results and fewer complications are observed when both fractures are diaphyseal than when one or both are intra-articular.

    • Keywords:
    • Femoral Fractures|Fracture Fixation|Humans|Joint Instability|Knee Injuries|Knee Joint|Multiple Trauma|Range of Motion

    • Articular|Tibial Fractures

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Arterial complications and total knee arthroplasty.

Arterial complications after total knee arthroplasty (TKA) are rare; however, the sequelae can be disastrous. Infection and the need for amputation or vascular reconstructive surgery are not uncommon. A thorough preoperative assessment can identify at-risk patients, many, if not all, of whom have preexisting peripheral arterial disease. In the presence of peripheral arterial disease, the use of a tourniquet during TKA has been implicated in subsequent arterial complications. Following the guidelines that have been established regarding preoperative assessment, the role of the vascular surgeon, and the use of a tourniquet before and during TKA can assist the orthopaedic surgeon in assessing candidates for TKA and reducing the risk of arterial complications.

    • Keywords:
    • Arterial Occlusive Diseases|Arteries|Arteriovenous Fistula|Arthroplasty

    • Replacement

    • Knee|Femoral Artery|Humans|Leg|Popliteal Artery|Postoperative Complications|Preoperative Care|Risk Factors|Thrombosis|Tourniquets|Vascular Diseases|Wounds

    • Nonpenetrating

    • Subspecialty:
    • Adult Reconstruction

Diffuse idiopathic skeletal hyperostosis: musculoskeletal manifestations.

Diffuse idiopathic skeletal hyperostosis (DISH) is a common disorder of unknown etiology that is characterized by back pain and spinal stiffness. There may be mild pain if ankylosis has occurred. The condition is recognized radiographically by the presence of "flowing" ossification along the anterolateral margins of at least four contiguous vertebrae and the absence of changes of spondyloarthropathy or degenerative spondylosis. Even in patients who present with either lumbar or cervical complaints, radiographic findings are almost universally seen on the right side of the thoracic spine. Thus, radiographic examination of this area is critical when attempting to establish a diagnosis of DISH. The potential sequelae of hyperostosis in the cervical and lumbar spine include lumbar stenosis, dysphagia, cervical myelopathy, and dense spinal cord injury resulting from even minor trauma. There may be a delay in diagnosis of spinal fractures in a patient with DISH because the patient often has a baseline level of spinal pain and because the injury may be relatively trivial. The incidence of delayed neurologic injury due to such fractures is high as a result of unrecognized instability and subsequent deterioration. Extraspinal manifestations are also numerous and include an increased risk of heterotopic ossification after total hip arthroplasty. Prophylaxis to prevent heterotopic ossification may be indicated for these patients.

    • Keywords:
    • Aged|Arthrography|Back Pain|Diagnosis

    • Differential|Female|Humans|Hyperostosis

    • Diffuse Idiopathic Skeletal|Joint Instability|Joints|Male|Middle Aged|Musculoskeletal Diseases|Ossification

    • Heterotopic|Pelvic Bones|Spinal Injuries|Spine

    • Subspecialty:
    • Spine

Muscle contusion injuries: current treatment options.

Muscle contusion is second only to strain as the leading cause of morbidity from sports-related injuries. Severity depends on the site of impact, the activation status of the muscles involved, the age of the patient, and the presence of fatigue. The diagnosis has traditionally been one of clinical judgment; however, newer modalities, including ultrasonography, magnetic resonance imaging, and spectroscopy, are becoming increasingly important in both identifying and delineating the extent of injury. Although controlled clinical studies are scarce, animal research into muscle contusions has allowed the description of the natural healing process, which involves a complex balance between muscle repair, regeneration, and scar-tissue formation. Studies are being performed to evaluate the effects of anti-inflammatory medications, corticosteroids, operative repair, and exercise protocols. Prevention and treatment of complications such as myositis ossificans have also been stressed, but recognition may improve the outcome of these ubiquitous injuries.

    • Keywords:
    • Animals|Anti-Inflammatory Agents

    • Non-Steroidal|Athletic Injuries|Contusions|Cryotherapy|Humans|Immobilization|Muscle Contraction|Muscle

    • Skeletal|Myositis Ossificans|Rats|Wound Healing

    • Subspecialty:
    • Sports Medicine

Trigger digits: diagnosis and treatment.

Stenosing tenosynovitis of the thumb and fingers is a very common problem seen by the primary-care physician, the orthopaedic surgeon, and the hand surgeon. Primary stenosing tenosynovitis is usually idiopathic and occurs more frequently in middle-aged women than in men, but can be seen even in infancy. Secondary stenosing tenosynovitis of the digits can occur in patients with rheumatoid arthritis, diabetes mellitus, gout, and other disease entities that cause connective tissue disorders. The diagnosis of triggering digits is generally not subtle and can be made on the basis of an adequate clinical examination. Classification according to the type of tenosynovitis and the time from onset of symptoms may be prognostically significant and may also affect the treatment outcome. As many as 85% of triggering fingers and thumbs can be treated successfully with corticosteroid injections and nonsteroidal anti-inflammatory drugs. Surgical release is generally indicated when nonoperative treatment fails. Percutaneous A1 pulley release can now be performed safely as an office procedure.

    • Keywords:
    • Adrenal Cortex Hormones|Adult|Child|Constriction

    • Pathologic|Decompression

    • Surgical|Female|Finger Joint|Humans|Injections

    • Intra-Articular|Male|Tenosynovitis|Thumb

    • Subspecialty:
    • Hand and Wrist

Wound irrigation in musculoskeletal injury.

Wound irrigation to remove debris and lessen bacterial contamination is an essential component of open fracture care. However, considerable practice variation exists in the details of technique. Volume is an important factor; increased volume improves wound cleansing to a point, but the optimal volume is unknown. High-pressure flow has been shown to remove more bacteria and debris and to lower the rate of wound infection compared with low-pressure irrigation, although recent in vitro and animal studies suggest that it may also damage bone. Pulsatile flow has not been demonstrated to increase efficacy. Antiseptic additives can kill bacteria in the wound, but host-tissue toxicities limit their use. Animal and clinical studies of the use of antiseptics in contaminated wounds have yielded conflicting outcomes. Antibiotic irrigation has been effective in experimental studies in some types of animal wounds, but human clinical data are unconvincing due to poor study design. There are few animal or clinical studies of musculoskeletal wounds. Detergent irrigation aims to remove, rather than kill, bacteria and has shown promise in animal models of the complex contaminated musculoskeletal wound.

    • Keywords:
    • Animals|Anti-Bacterial Agents|Anti-Infective Agents

    • Local|Bacterial Infections|Drug Delivery Systems|Fractures

    • Open|Humans|Irrigation|Surface-Active Agents|Wound Infection

    • Subspecialty:
    • Trauma

    • General Orthopaedics

    • Basic Science