Instructional course lectures
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Neural injuries that occur after total hip arthroplasty (THA) can be classified as involving either the central nervous system or peripheral nerves. Central nervous system changes after THA may be attributed to increased appreciation of fat embolism syndrome associated with THA. Certain maneuvers such as impacting the acetabulum, femoral reaming, and cement pressurization can force marrow fat into the venous system. ⋯ The mechanisms of vascular injury include occlusion associated with preexisting peripheral vascular disease and vascular injury during removal of cement during screw fixation of acetabular components, cages, or structural grafts. Perioperative assessment should include vascular evaluation of patients with absent pulses, previous vascular bypass surgery, or dysvascular limbs. A CT scan should be considered when cement or components extend medially into the pelvis.
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Closed tibial shaft fractures are common injuries that remain challenging to treat because of the wide spectrum of fracture patterns and soft-tissue injuries. Understanding the indications for surgical and nonsurgical treatment of these fractures is essential for good outcomes. Although cast treatment of stable tibial shaft fractures has traditionally been successful and continues to be widely used, recent clinical studies have shown that intramedullary nails may be more advantageous for fracture healing and function than casting. ⋯ Metaphyseal fractures are well suited for plates, although newer intramedullary nail designs provide the option of intramedullary nailing of proximal or distal metaphyseal tibia-fibula fractures. External fixators are well suited for skeletally immature patients with unstable fracture patterns or for patients with unacceptably small intramedullary canals. Interlocking intramedullary nails are the treatment of choice for most unstable tibia-fibula shaft fractures.
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The treatment of open fractures of the tibial shaft continues to be a challenging problem for the orthopaedic surgeon. The basic principles of treatment for open fractures have changed little over the past decade; urgent wound débridement, early use of antibiotic therapy, skeletal stabilization, and early wound coverage remain the primary goals of treatment. However, the methods used to achieve these goals of treatment have evolved. Recent advances in the treatment of open fractures focus on the treatment of open fractures of the tibial shaft.
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Neck pain is a common complaint that typically represents a spectrum of disorders affecting the cervical spine. The clinical history and examination of patients with neck pain dictate the proper timing and selection of diagnostic studies such as plain radiography, MRI, and myelography with CT. ⋯ Nonsurgical treatment is the most appropriate first step in almost all cases of cervical radiculopathy. In contrast, the conservative care of cervical spondylotic myelopathy with measures such as physical therapy, spinal manipulation, medications, collars, and traction is limited.
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Scaphoid fractures are among the most common fractures of the bones of the wrist and usually result from a forceful extension of the wrist. If the diagnosis cannot be established by clinical and radiographic examination, bone scans are recommended and are preferred over tomography or MRI, which are more expensive diagnostic procedures. Scaploid fractures should be classified as either undisplaced, stable or displaced, unstable. ⋯ The recommended treatment for unstable scaphoid fractures is open reduction and screw fixation. Closed reduction and percutaneous screw or pin fixation can be considered in minimally displaced or reducible fractures, whereas open reduction is recommended for all other displaced fractures. The following treatment protocols are recommended: (1) bone scan or, if necessary, tomography for early diagnosis; (2) percutaneous screw fixation of nondisplaced or minimally displaced scaphoid fractures as an alternative to treatment with a thumb spica cast; (3) open reduction of displaced scaphoid fractures; (4) early mobilization of stable fractures after internal fixation; and (5) the possible use of a playing splint after athletic injuries when secure internal fixation is achieved.