J Am Acad Orthop Sur
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J Am Acad Orthop Sur · Jan 2000
ReviewBallistics and gunshot wounds: effects on musculoskeletal tissues.
As a result of the increasing number of weapons in this country, as many as 500,000 missile wounds occur annually, resulting in 50,000 deaths, significant morbidity, and striking socioeconomic costs. Wounds are generally classified as low-velocity (less than 2,000 ft/sec) or high-velocity (more than 2,000 ft/sec). However, these terms can be misleading; more important than velocity is the efficiency of energy transfer, which is dependent on the physical characteristics of the projectile, as well as kinetic energy, stability, entrance profile and path traveled through the body, and the biologic characteristics of the tissues injured. ⋯ Evaluation of the "four Cs"-color, consistency, contractility, and capacity to bleed-provides valuable information regarding the viability of muscle. Skin grafting is preferable when tension is required for wound closure, although other soft-tissue procedures, such as use of local rotation flaps or free tissue transfer, may be necessary, especially for shotgun wounds. Distal neurologic deficit alone is not an indication for exploration, as it often resolves without surgical intervention.
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J Am Acad Orthop Sur · Nov 1999
ReviewFractures of the base of the first metacarpal: current treatment options.
Fractures of the thumb metacarpal occur most frequently at the base. These fractures can be subdivided into intra-articular and extra-articular types. Intra-articular fractures present treatment challenges because they have a tendency to displace due to deforming forces acting at the base of the thumb. ⋯ In the case of severely comminuted intra-articular fractures, articular impaction has been implicated as one of the causes of posttraumatic arthritis. It is difficult to restore the articular surface in these injuries. Therefore, external fixation can be considered when the fracture fragments are small and there is significant soft-tissue injury.
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Cervical spine injuries have been estimated to occur in 10% to 15% of football players, most commonly in linemen, defensive ends, and linebackers. The overwhelming majority of such injuries are self-limited, and full recovery can be expected. However, the presenting symptoms of serious cervical spine injuries may closely resemble those of minor injuries. ⋯ These decisions can have an enormous impact on the player and his family. Most severe cervical spine injuries share the common mechanism of application of an axial load to the straightened spine. Avoiding techniques that employ head-down "spear" tackling and wearing properly fitted equipment markedly reduce the risk of serious injury.
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The hallucal sesamoids, although small and seemingly insignificant, play an important role in the function of the great toe by absorbing weight-bearing pressure, reducing friction, and protecting tendons. However, the functional complexity and anatomic location of these small bones make them vulnerable to injury from shear and loading forces. Injury to the hallucal sesamoids can cause incapacitating pain, which can be devastating to an athlete. ⋯ Careful physical and radiologic examinations are necessary to determine the cause of pain and allow a recommendation of the optimal treatment. Surgical treatment may include partial or complete resection of the sesamoid, shaving of a prominent tibial sesamoid, or autogenous bone grafting for nonunion. Excision of both sesamoids should be avoided if possible.
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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. ⋯ 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.