JAAOS, Volume 5, No. 3

Complex Articular Fractures of the Distal Radius: Classification and Management.

Articular fractures of the distal radius require an anatomic reduction, as even minimal step-offs are associated with the development of osteoarthritis. Such fractures are classified on the basis of both the mechanism and the pattern of injury. The comprehensive classification of fractures established by Muller et al defines those occurring from a shearing mechanism and involving part of the articular surface as type B fractures. These are in turn subdivided into group B1 fractures, which involve the radial styloid (chauffeur's fracture); group B2, which involve the dorsal margin of the radius; and group B3, which involve the volar margin of the distal radius (Barton's fracture). Type B fractures are unstable and often require operative intervention. Articular fractures resulting from a compression force on the end of the radius are classified as type C. A group C1 fracture is a two-part fracture without metaphyseal comminution; group C2, a two-part fracture with metaphyseal comminution; group C3, a fracture with more than two pieces, with or without comminution. The operative tactic for compression fractures involves restoration of the four common fragments in sequence. This can often be accomplished by manipulative means alone or with limited exposure of the fracture fragments and stabilization with percutaneous Kirschner wires. Neutralization with an external fixator and use of an autogenous bone graft are often required.

      • Subspecialty:
      • Trauma

      • Hand and Wrist

    Frozen Shoulder: Diagnosis and Management.

    "Frozen shoulder" comprises a group of conditions caused by different processes. Effective treatment depends on recognition of the underlying pathologic dis-order in each individual case. Idiopathic adhesive capsulitis usually responds to nonoperative therapy or closed manipulation, but shoulder stiffness due to trauma or surgery may necessitate either an arthroscopic or an open-release procedure. Both of these technically demanding techniques are effective in restoring motion in cases of frozen shoulder refractory to nonoperative treatment.

        • Subspecialty:
        • Shoulder and Elbow

      Soft-Tissue Tumors About the Knee.

      Soft-tissue tumors about the knee include a wide variety of entities, ranging from synovial cysts to aggressive high-grade sarcomas. The overlap in clinical presentation of these various masses frequently results in misdiagnosis and inappropriate treatment. Unnecessary and sometimes costly arthroscopy sometimes precedes the diagnosis of soft-tissue sarcoma about the knee. A poorly planned or executed biopsy has been demonstrated to have an adverse effect on patient prognosis and may lead to unnecessary amputation. Special vigilance in evaluation is warranted when a soft-tissue mass is not in the typical position or does not have other characteristic features of a meniscal or Baker's cyst, when the size of the mass or the accompanying symptoms seem out of proportion to the injury or underlying degenerative process, and when symptoms persist beyond what is expected. When malignancy is suspected, the patient should be referred to a musculoskeletal oncologist before biopsy.

          • Subspecialty:
          • Musculoskeletal Oncology

        Pseudarthrosis of the Lumbar Spine.

        Pseudarthrosis can be a costly and disabling complication of lumbar spinal fusion. This review focuses on the incidence, causation, diagnosis, and nonoperative management of this condition, as well as surgical approaches that can be effective in treating carefully selected patients. Judicious initial selection of patients for fusion and the use of meticulous surgical technique in the first operation continue to be the best means of prevention.

            • Subspecialty:
            • Spine

          Supracondylar Fractures of the Femur.

          Successful management of the distal femoral fracture is possible with adherence to the basic principles of anatomic reduction, stable fixation, and early motion. Closed management can achieve these goals in selected patients, but most supracondylar femoral fractures are better treated with operative reconstruction. Implant selection is determined on the basis of the characteristics of the fracture, the bone quality, the needs of the patient, and the experience of the surgeon. Surgical options include the angled blade plate, compression-screw systems, condylar buttress plates, intramedullary nails, external fixation, and modular distal femoral replacement. The author reviews the indications and techniques for using these devices.

              • Subspecialty:
              • Trauma

            Injuries to the Distal Lower Extremity Syndesmosis.

            Disruption of the distal syndesmosis of the lower extremity is most commonly associated with ankle fractures but can also occur without gross bone injury. Definitive management of these injuries remains controversial. The current indications for syndesmosis fixation are based on tibiotalar joint mechanics as determined in cadaveric and biomechanical studies, as well as radiologic evaluation and an understanding of the pertinent anatomy and the etiology of these injuries. Such data support the use of syndesmotic screws in selected fractures that include a disruption of the syndesmosis. However, definitive fixation recommendations for syndesmosis disruption with or without ankle fracture remain under investigation. Distal lower extremity syndesmosis sprains without fracture or subluxation consistently require longer recovery time than typical lateral sprains and can be associated with greater long-term disability.

                • Subspecialty:
                • Trauma

                • Foot and Ankle