JAAOS, Volume 14, No. 5

Posterior capsular contracture of the shoulder.

Posterior capsular contracture is a common cause of shoulder pain in which the patient presents with restricted internal rotation and reproduction of pain. Increased anterosuperior translation of the humeral head occurs with forward flexion and can mimic the pain reported with impingement syndrome; however, the patient with impingement syndrome presents with normal range of motion. Initial management of posterior capsular contracture should be nonsurgical, emphasizing range-of-motion stretching with the goal of restoring normal motion. For patients who fail nonsurgical management, arthroscopic posterior capsule release can result in improved motion and pain relief. In the throwing athlete, repetitive forces on the posteroinferior capsule may cause posteroinferior capsular hypertrophy and limited internal rotation. This may be the initial pathologic event in the so-called dead arm syndrome, leading to a superior labrum anteroposterior lesion and, possibly, rotator cuff tear. Management involves regaining internal rotation such that the loss of internal rotation is not greater than the increase in external rotation. In the athlete who fails nonsurgical management, a selective posteroinferior capsulotomy can improve motion, reduce pain, and prevent further shoulder injury.

    • Keywords:
    • Arthroscopy|Athletic Injuries|Contracture|Humans|Joint Capsule|Ligaments

    • Articular|Physical Therapy Modalities|Range of Motion

    • Articular|Rotation|Shoulder Impingement Syndrome|Shoulder Joint|Shoulder Pain

    • Subspecialty:
    • Sports Medicine

    • Shoulder and Elbow

Complex elbow instability.

Complex elbow instability consists of dislocation of the ulnohumeral joint with a concomitant fracture of one or several of the bony stabilizers of the elbow, including the radial head, proximal ulna, coronoid process, or distal humerus. Recurrent instability is not often associated with simple dislocation, but an improperly managed complex dislocation may be a prelude to chronic, recurrent elbow instability. Complex instability is significantly more demanding to manage than simple instability. Radial head, coronoid, and olecranon fracture associated with dislocation each must be assessed and often require surgery. Long-term outcome with surgical management of complex elbow injuries is unknown. A few published series examine combinations of different injury patterns managed with various methods. Recently, however, several well-designed prospective outcome studies have evaluated management of several different individual fracture-dislocation patterns with a unified treatment algorithm. Fixation or replacement of injured bony elements, ligamentous repair, and hinged fixation may be used to successfully manage complex elbow instability.

    • Keywords:
    • Collateral Ligaments|Dislocations|Elbow Joint|Fracture Fixation|Fractures

    • Comminuted|Humans|Joint Instability|Monteggias Fracture|Radius Fractures

    • Subspecialty:
    • Shoulder and Elbow

    • Hand and Wrist

Displaced femoral neck fractures in the elderly: hemiarthroplasty versus total hip arthroplasty.

The incidence of femoral neck fracture among the elderly in the United States is expected to increase dramatically because of the anticipated explosion in the population aged 65 years and older, increased life expectancy, and the rising incidence of osteoporosis. The resulting public health implications may be significant, with annual hospital admissions resulting from hip fracture projected to increase to 700,000 by 2050, and with annual spending on hip fracture care expected to exceed 15 billion dollars within a few years. The decision to perform internal fixation, unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA must be based on patient mental status, living arrangement, level of independence and activity, and bone and joint quality.

    • Keywords:
    • Aged|Algorithms|Arthroplasty

    • Replacement

    • Hip|Femoral Neck Fractures|Fracture Fixation

    • Internal|Hip Prosthesis|Humans|Prosthesis Design|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Adult Reconstruction

Congenital and developmental deformities of the spine in children with myelomeningocele.

The treatment of spinal deformities in children with myelomeningocele poses a formidable task. Multiple medical comorbidities, such as insensate skin and chronic urinary tract infection, make care of the spine difficult. A thorough understanding of the natural history of these deformities is mandatory for appropriate treatment to be rendered. A team approach that includes physicians from multiple specialties provides the best care for these patients. The two most challenging problems are paralytic scoliosis and rigid lumbar kyphosis. The precise indications for surgical intervention are multifactorial, and the proposed benefits must be weighed against the potential risks. Newer spinal constructs now allow for fixation of the spine in areas previously difficult to instrument. Complications appear to be decreasing with improved understanding of the pathophysiology associated with myelomeningocele.

    • Keywords:
    • Bone Diseases

    • Developmental|Braces|Child|Comorbidity|Humans|Kyphosis|Meningomyelocele|Osteotomy|Postoperative Complications|Pseudarthrosis|Scoliosis|Spine|Syringomyelia

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

Renal osteodystrophy.

The incidence of chronic renal disease is increasing, and the pattern of renal osteodystrophy seems to be shifting from the classic hyperparathyroid presentation to one of low bone turnover. Patients with persistent disease also live longer than previously and are more physically active. Thus, patients may experience trauma as a direct result of increased physical activity in a setting of weakened pathologic bone. Patient quality of life is primarily limited by musculoskeletal problems, such as bone pain, muscle weakness, growth retardation, and skeletal deformity. Chronic renal disease also increases the risk of comorbidity, such as infection, bleeding, and anesthesia-related problems. Current treatment strategies include dietary changes, plate-and-screw fixation, and open reduction and internal fixation.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Bone Density|Bone and Bones|Hip Prosthesis|Humans|Kidney|Osteoarthritis

    • Hip|Parathyroid Hormone|Prosthesis-Related Infections|Renal Osteodystrophy

    • Subspecialty:
    • General Orthopaedics