Instructional course lectures
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Proximal femoral fractures in the skeletally immature patient can be challenging for the orthopaedic surgeon to manage. This type of injury includes the femoral head/neck, intertrochanteric, and subtrochanteric fractures. ⋯ Although the understanding of proximal femur fractures has improved, many of the risk factors for poor outcomes in these injuries are not modifiable. Familiarity with the history, classification, complications, factors influencing the outcome, and management options available in 2018 will help improve the outcomes of pediatric proximal femur fractures.
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Knee injuries are common in children, but epiphyseal and physeal injuries involving the distal femur and proximal tibia are relatively rare. This can make diagnosis and evaluation of pediatric knee injuries challenging. Pediatric knee physeal injuries can also be complicated by vascular injuries with potentially devastating consequences, and thus, a heightened suspicion for these injuries is indicated. ⋯ Patellar sleeve injuries are often misdiagnosed and may require advanced imaging for diagnosis. They represent pediatric extensor mechanism injuries that often necessitate open reduction and fixation or patellar tendon advancement. Understanding the relevant anatomy, diagnosis, and management options can help guide the treating physician in the management of the fractures of the pediatric knee.
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Although perilunate injuries represent only 5% of all carpal injuries, they compose a spectrum of devastating complex wrist injuries. Perilunate injuries result from high-energy trauma to the wrist and may be associated with multiple fractures, dislocations, and ligament injuries. Although the diagnosis of a perilunate injury is made via radiographic assessment, missed diagnosis occurs in 25% of patients with a perilunate injury. ⋯ Radiocarpal fracture-dislocations generally result from high-energy trauma and are characterized by a carpal dislocation, which usually involves a small portion of the rim of the dorsal or volar aspect of the distal radius. Neurologic dysfunction and elevated intracompartment pressure may be present in patients with a radiocarpal fracture-dislocation. Wrist fracture-dislocations are associated with a number of complications, including intercarpal instability, later arthrosis, carpal nonunion, and loss of radiocarpal mobility.
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Thoracic outlet syndrome is a disorder caused by thoracic outlet compression of the brachial plexus and/or the subclavian vessels. The characteristics of thoracic outlet syndrome are highly variable. ⋯ Surgeons who accept the existence of thoracic outlet syndrome acknowledge that diagnosis is clinical. The variability and complexity of thoracic outlet syndrome lends itself to mistakes in both diagnosis and surgical treatment.
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At one time, anterior cruciate ligament (ACL) tears in skeletally immature patients were considered rare. The recommended treatment option for skeletally immature patients with ACL tears was to modify activities until skeletal maturity, at which point definitive ACL reconstruction could be safely performed. The management of ACL tears in skeletally immature patients has evolved as a result of the increased frequency of ACL tears in younger patients and an increased awareness for the potential development or worsening of meniscal tears, chondral lesions, and degenerative changes that occur with the "wait-and-fix-later" approach. ⋯ The timing and ideal technique for ACL reconstruction in skeletally immature patients are controversial. Accurate assessment of skeletal growth remaining and concerns for iatrogenic growth disturbances continually challenge treating physicians. Similar controversies with regard to the treatment of skeletally immature patients who have partial ACL tears or congenital absence of the ACL also exist.