J Am Acad Orthop Sur
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Pediatric cervical spine injuries are rare and are associated with significant morbidity and mortality. Pediatric anatomy and physiology predispose to upper cervical spine injury and spinal cord injury without radiologic abnormality in contrast to lower cervical spine injury seen in adults. ⋯ Definitive management of pediatric cervical spine trauma must be adapted to the distinctive anatomy and growth potential of the patient. As with all injuries, prevention is necessary to reduce the incidence of trauma to the pediatric spine.
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J Am Acad Orthop Sur · Oct 2011
ReviewBiologic and pharmacologic augmentation of rotator cuff repairs.
As rotator cuff repair techniques have improved, failure of the tendon to heal to the proximal humerus is less likely to occur from weak tendon-to-bone fixation. More likely causes of failure include biologic factors such as intrinsic tendon degeneration, fatty atrophy, fatty infiltration of muscle, and lack of vascularity of the tendons. High failure rates have led to the investigation of biologic augmentation to potentially enhance the healing response. ⋯ In animal models, growth factors and their delivery scaffolds as well as tissue engineering have shown promise in decreasing scar tissue while maintaining biomechanical strength. Platelet-rich plasma may be a safe adjuvant to rotator cuff repair, but it has not been shown to improve healing or function. Many of these strategies need to be further defined to permit understanding of, and to optimize, the biologic environment; in addition, techniques need to be refined for clinical use.
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Adhesive capsulitis is characterized by painful, gradual loss of active and passive shoulder motion resulting from fibrosis and contracture of the joint capsule. Other shoulder pathology can produce a similar clinical picture, however, and must be considered. Management is based on the underlying cause of pain and stiffness, and determination of the etiology is essential. ⋯ Indications for surgery should be individualized. Failure to obtain symptomatic improvement and continued functional disability following ≥6 months of physical therapy is a general guideline for surgical intervention. Diligent postoperative therapy to maintain motion is required to minimize recurrence of adhesive capsulitis.
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Perilunate dislocations and perilunate fracture-dislocations usually result from high-energy traumatic injuries to the wrist and are associated with a characteristic spectrum of bony and ligamentous damage. Radiographic evaluation of the wrist reveals loss of normal radiocarpal and intercarpal colinearity and bony insult, which may be overlooked at the initial presentation. Prompt recognition is important to optimize outcomes. ⋯ Complications include posttraumatic arthrosis, median nerve dysfunction, complex regional pain syndrome, tendon problems, and carpal instability. Despite appropriate treatment, loss of wrist motion and grip strength, as well as persistent pain, is common. Medium- and long-term studies demonstrate radiographic evidence of midcarpal and radiocarpal arthrosis, although this does not correlate with functional outcomes.
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Most clavicle fractures heal without difficulty. However, radiographic nonunion after distal clavicle fracture has been reported in 10% to 44% of patients. Type II distal clavicle fractures, which involve displacement, are associated with the highest incidence of nonunion. ⋯ The decision whether to operate may be influenced by the amount of fracture displacement and the individual demands of the patient. Surgical options to achieve bony union include transacromial wire fixation, a modified Weaver-Dunn procedure, use of a tension band, screw fixation, plating, and arthroscopy. Each technique has advantages and disadvantages; insufficient evidence exists to demonstrate that any one technique consistently provides the best results.