JAAOS

JAAOS, Volume 9, No. 5


Axillary nerve injury: diagnosis and treatment.

Axillary nerve injury is infrequently diagnosed but is not a rare occurrence. Injury to the nerve may result from a traction force or blunt trauma applied to the shoulder. The most common zone of injury is just proximal to the quadrilateral space. Atraumatic causes of neuropathy include brachial neuritis and quadrilateral space syndrome. The vast majority of patients recover with non-operative treatment. Baseline electromyographic and nerve conduction studies should be obtained within 4 weeks after injury, with a follow-up evaluation at 12 weeks. If no clinical or electromyographic improvement is noted, surgery may be appropriate. The results of operative repair are best if surgery is performed within 3 to 6 months from the injury. Surgical options include neurolysis, nerve grafting, and neurotization. The results of repair of axillary nerve injuries have been good compared with treatment of other peripheral nerve lesions, due to the monofascicular composition of the nerve and the relatively short distance between the zone of injury and the motor end-plate.

    • Keywords:
    • Brachial Plexus|Humans|Neurosurgical Procedures|Shoulder

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

Bioabsorbable implants in orthopaedics: new developments and clinical applications.

The use of bioabsorbable implants in orthopaedic surgical procedures is becoming more frequent. Advances in polymer science have allowed the production of implants with the mechanical strength necessary for such procedures. Bioabsorbable materials have been utilized for the fixation of fractures as well as for soft-tissue fixation. These implants offer the advantages of gradual load transfer to the healing tissue, reduced need for hardware removal, and radiolucency, which facilitates postoperative radiographic evaluation. Reported complications with the use of these materials include sterile sinus tract formation, osteolysis, synovitis, and hypertrophic fibrous encapsulation. Further study is required to determine the clinical situations in which these materials are of most benefit.

    • Keywords:
    • Absorbable Implants|Biodegradation

    • Environmental|Biomechanics|Fracture Fixation|Humans|Joints|Orthopedic Fixation Devices|Polymers|Sutures

    • Subspecialty:
    • Trauma

    • General Orthopaedics

    • Basic Science

Meralgia paresthetica: diagnosis and treatment.

Meralgia paresthetica is a symptom complex that includes numbness, paresthesias, and pain in the anterolateral thigh, which may result from either an entrapment neuropathy or a neuroma of the lateral femoral cutaneous nerve (LFCN). The condition can be differentiated from other neurologic disorders by the typical exacerbating factors and the characteristic distribution of symptoms. The disease process can be either spontaneous or iatrogenic. The spontaneous form is usually mechanical in origin. The LFCN is subject to compression throughout its entire course. Injuries most commonly occur as the nerve exits the pelvis. The regional anatomy of the LFCN is highly varied and may account for its susceptibility to local trauma. Relief of pain and paresthesias after injection of a local anesthetic agent is helpful in establishing the diagnosis. If no improvement is found, proximal LFCN irritation should be sought. Idiopathic meralgia paresthetica usually improves with nonoperative modalities, such as removal of compressive agents, nonsteroidal anti-inflammatory drugs, and, if necessary, local corticosteroid injections. If intractable pain persists despite such measures, surgery can be considered, although whether neurolysis or transection is the procedure of choice is still controversial. Iatrogenic meralgia paresthetica has been found to occur after a number of orthopaedic procedures, such as anterior iliac-crest bone-graft harvesting and anterior pelvic procedures. Prone positioning for spine surgery has also been implicated. Variations in the anatomy of the LFCN about the anterior superior iliac spine may place the nerve at higher risk for damage. Although nonoperative management usually results in satisfactory results, efforts should be made to avoid injury at the time of surgery.

    • Keywords:
    • Diagnosis

    • Differential|Femoral Nerve|Femoral Neuropathy|Humans|Nerve Compression Syndromes|Paresthesia

    • Subspecialty:
    • Trauma

    • Sports Medicine

    • Shoulder and Elbow

    • General Orthopaedics

    • Basic Science

Orthopaedics in the developing world: present and future concerns.

Half of the world's population lack access to adequate primary health care, and two thirds lack access to orthopaedic care. Globally, the need for health care outstrips the available resources. This problem is compounded in the developing world by a lack of trained medical personnel, a lack of medical facilities, and, in many regions, an inability to access existing facilities. There is little specific epidemiologic data about the exact burden of musculoskeletal disease in these countries, but most agree that it is reasonable to assume that it will increase. In the least developed and developing nations, problems with access are related to fundamental issues such as infrastructure, physical facilities, equipment, and trained personnel. There are a number of ways in which the orthopaedic community can become involved in ameliorating the burden. Education is the most effective method of providing a sustainable solution. The objective of educational organizations should be to train local health-care workers at all levels in their own environment to provide sustainable and appropriate care so that the programs become self-sufficient and ensure a continued supply of competent medical personnel.

    • Keywords:
    • Developing Countries|Health Services Accessibility|Humans|International Cooperation|Musculoskeletal Diseases|Orthopedics

    • Subspecialty:
    • General Orthopaedics

Pediatric foot fractures: evaluation and treatment.

Foot fractures account for 5% to 8% of all pediatric fractures and for approximately 7% of all physeal fractures. A thorough understanding of the anatomy of the child's foot is of central importance when treating these injuries. Due to the difficulties that may be encountered in obtaining an accurate physical examination of a child with a foot injury and the complexities of radiographic evaluation of the immature foot, a high index of suspicion for the presence of a fracture facilitates early and accurate diagnosis. Although the treatment results in pediatric foot trauma are generally good, potential pitfalls in the treatment of Lisfranc fractures, talar neck and body fractures, and lawn mower injuries to the foot must be anticipated and avoided if possible.

    • Keywords:
    • Child|Dislocations|Foot|Foot Injuries|Fractures

    • Bone|Humans

    • Subspecialty:
    • Trauma

    • Foot and Ankle

    • Pediatric Orthopaedics

Pneumatic tourniquets in extremity surgery.

Pneumatic tourniquets maintain a relatively bloodless field during extremity surgery, minimize blood loss, aid identification of vital structures, and expedite the procedure. However, they may induce an ischemia-reperfusion injury with potentially harmful local and systemic consequences. Modern pneumatic tourniquets are designed with mechanisms to regulate and maintain pressure. Routine maintenance helps ensure that these systems are working properly. The complications of tourniquet use include postoperative swelling, delay of recovery of muscle power, compression neurapraxia, wound hematoma with the potential for infection, vascular injury, tissue necrosis, and compartment syndrome. Systemic complications can also occur. The incidence of complications can be minimized by use of wider tourniquets, careful preoperative patient evaluation, and adherence to accepted principles of tourniquet use.

    • Keywords:
    • Emergencies|Extremities|Hemostasis

    • Surgical|Humans|Orthopedic Procedures|Reperfusion Injury|Tourniquets

    • Subspecialty:
    • Trauma

    • Sports Medicine

    • Shoulder and Elbow

    • General Orthopaedics

    • Basic Science

Posterior cruciate ligament injuries: evaluation and management.

Posterior cruciate ligament (PCL) injuries commonly occur during sports participation or as a result of motor vehicle accidents. Careful history taking and a comprehensive physical examination are generally sufficient to identify PCL injuries. Most authors recommend nonoperative treatment for acute isolated PCL tears. This involves initial splinting in extension followed by range-of-motion and strengthening exercises. Recovery of quadriceps strength is necessary to compensate for posterior tibial subluxation and to facilitate return to preinjury activity levels. In isolated PCL tears, surgical treatment is reserved for acute bone avulsions and symptomatic chronic high-grade PCL tears. Arthroscopic single-tunnel reconstruction techniques will improve posterior laxity only moderately. Newer double-tunnel and tibial-inlay techniques offer theoretical advantages, but the available clinical results are only preliminary. When a PCL injury occurs in combination with other ligament injuries, most patients will require surgical treatment.

    • Keywords:
    • Humans|Knee Injuries|Orthopedic Procedures|Physical Examination|Posterior Cruciate Ligament

    • Subspecialty:
    • Sports Medicine

Primary osteoarthritis of the hip: etiology and epidemiology.

Primary osteoarthritis (OA) of the hip has a distinct etiology and epidemiology compared with other types of arthropathy in the hip joint. Arthritis of the hip can be secondary to conditions such as osteonecrosis, trauma, sepsis, or rheumatoid arthritis. Certain conditions, such as congenital hip disease and slipped capital femoral epiphysis, involve predisposing anatomic abnormalities; in such cases, the term "secondary OA" is used. When either an anatomic abnormality cannot be determined or other specific causative entities are not identified, primary OA is the diagnosis of exclusion. The prevalence of hip OA is about 3% to 6% in the Caucasian population and has not changed in the past four decades. In contrast, studies in Asian, black, and East Indian populations indicate a very low prevalence of hip OA. Statistics on patients who underwent total hip replacement for primary OA in San Francisco and Hawaii demonstrate a virtual absence of the condition in Asians and low rates in the black and Hispanic populations. Family studies from Sweden, Britain, and the United States show increased rates of hip OA in first-degree relatives of the index patient when compared with the normal population. Occupations requiring heavy lifting, farming, and elite sports activity are associated with increased rates of hip OA. The low prevalence of hip OA in Asian and black populations in their native countries; the low incidence of total joint replacement for primary OA in Asian, black, and Hispanic populations in North America; and the familial association of hip OA in Caucasians all suggest that genetic factors may be involved in the occurrence of this disease.

    • Keywords:
    • Ethnic Groups|Europe|Humans|Osteoarthritis

    • Hip|Prevalence|Sex Characteristics

    • Subspecialty:
    • Adult Reconstruction

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