J Am Acad Orthop Sur
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J Am Acad Orthop Sur · May 1999
Approach to the polytraumatized patient with musculoskeletal injuries.
The management of the multiply injured patient is a challenge for even experienced clinicians. Because many community hospitals lack a dedicated trauma team, it is often the orthopaedic surgeon who will direct treatment. Therefore, the orthopaedic surgeon must have an understanding of established guidelines for the evaluation, resuscitation, and care of the severely injured patient. ⋯ The secondary survey, which is often neglected, must incorporate a thorough physical evaluation. Although the method of fracture stabilization is still controversial, most clinicians agree that early fixation offers many benefits, including early mobilization, improved pulmonary toilet, decreased cardiovascular risk, and improved psychological well-being. Without an understanding of the complexities of the multiply injured patient, delays in the diagnosis and treatment of a patient's injuries are likely to adversely affect outcome.
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Rupture of the distal biceps tendon occurs most commonly in the dominant extremity of men between 40 and 60 years of age when an unexpected extension force is applied to the flexed arm. Although previously thought to be an uncommon injury, distal biceps tendon ruptures are being reported with increasing frequency. The rupture typically occurs at the tendon insertion into the radial tuberosity in an area of preexisting tendon degeneration. ⋯ The patient with a chronic rupture may benefit from surgical reattachment, but proximal retraction and scarring of the muscle belly can make tendon mobilization difficult, and inadequate length of the distal biceps tendon may necessitate tendon augmentation. Postoperative rehabilitation must emphasize protected return of motion for the first 8 weeks after repair. Formal strengthening may begin as early as 8 weeks, with a return to unrestricted activities, including lifting, by 5 months.
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J Am Acad Orthop Sur · Mar 1999
ReviewAnesthesia and analgesia for the ambulatory management of fractures in children.
The goal of anesthesia in the ambulatory management of fractures in children is to provide analgesia and relieve anxiety in order to facilitate successful closed treatment of the skeletal injury. Numerous techniques short of general anesthesia are available. These methods include blocks (local, regional, and intravenous), sedation (conscious and deep), and dissociative anesthesia (ketamine sedation). ⋯ Sedation with inhalation agents, such as nitrous oxide, and parenterally administered narcotic-benzodiazepine combinations, are not region-specific and are suitable for patients over a wide range of ages. Ketamine sedation is an excellent choice for children less than 10 years old. With any technique, proper monitoring and adherence to safety guidelines are essential.
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J Am Acad Orthop Sur · Mar 1999
ReviewSurgical treatment of acetabular fractures in elderly patients with osteoporotic bone.
The incidence of acetabular fractures in the elderly has recently shown a marked increase due to the combination of greater longevity for the population as a whole and a relative decrease in the incidence of alcohol-related trauma in younger adults. The compromised physiologic reserve and the diminished healing capacity of the typical elderly patient have an adverse effect on the potential for a favorable clinical outcome. The presence of osteopenic bone or degenerative arthritis and the effects of previous radiation therapy to the hip and pelvis hamper diagnostic imaging and the utility of some treatment alternatives that were designed primarily for younger patients. ⋯ The feasibility of acute total hip arthroplasty rests on the use of newly developed techniques for minimally invasive stabilization of the acetabular fracture with cables and the application of morselized or structural autograft harvested from the femoral head. Whichever surgical method is chosen, the objective is rapid mobilization of the patient on a walker or crutches. Late complications that may occur after nonoperative or operative treatment include posttraumatic arthritis, nonunion, wound infection, and heterotopic bone formation.
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J Am Acad Orthop Sur · Sep 1998
ReviewExtremity fractures in the patient with a traumatic brain injury.
Extremity fractures are common in patients with traumatic brain injuries (TBIs). These injuries are often inadequately treated and occasionally are completely missed due to the unique problems inherent to the TBI patient. However, appropriate evaluation of the TBI patient allows prompt diagnosis and optimal treatment of extremity fractures. ⋯ Upper extremity fractures are often associated with peripheral nerve injuries. Heterotopic ossification is common, especially about the elbow and hip. Contrary to prevalent belief, fracture healing is not necessarily accelerated in the TBI patient; hypertrophic callus, myositis ossificans, and heterotopic ossification occur frequently and are often misperceived as accelerated healing.