JAAOS, Volume 8, No. 1

Orthopaedic aspects of child abuse.

Increased awareness of child abuse has led to better understanding of this complex problem. However, the annual incidence of abuse is estimated at 15 to 42 cases per 1,000 children and appears to be increasing. More than 1 million children each year are the victims of substantiated abuse or neglect, and more than 1,200 children die each year as a result of abuse. The diagnosis of child abuse is seldom easy to make and requires a careful consideration of sociobehavioral factors and clinical findings. Because manifestations of physical abuse involve the entire child, a thorough history and a complete examination are essential. Fractures are the second most common presentation of physical abuse after skin lesions, and approximately one third of abused children will eventually be seen by an orthopaedic surgeon. Thus, it is essential that the orthopaedist have an understanding of the manifestations of physical abuse, to increase the likelihood of recognition and appropriate management. There is no pathognomonic fracture pattern in abuse. Rather, the age of the child, the overall injury pattern, the stated mechanism of injury, and pertinent psychosocial factors must all be considered in each case. Musculoskeletal injury patterns suggestive of nonaccidental injury include certain metaphyseal lesions in young children, multiple fractures in various stages of healing, posterior rib fractures, and long-bone fractures in children less than 2 years old. Skeletal surveys and bone scintigraphy with follow-up radiography may be of benefit in cases of suspected abuse of younger children. The differential diagnosis of abuse includes other conditions that may cause fractures, such as true accidental injury, osteogenesis imperfecta, and metabolic bone disease. Management should be multidisciplinary, with the key being recognition, because abused children have a substantial risk of repeated abuse and death.

    • Keywords:
    • Child|Child Abuse|Child

    • Preschool|Diagnosis

    • Differential|Fractures

    • Bone|Humans|Incidence|Infant|Musculoskeletal System|Skin

    • Subspecialty:
    • Trauma

    • Pediatric Orthopaedics

    • General Orthopaedics

Ballistics and gunshot wounds: effects on musculoskeletal tissues.

As a result of the increasing number of weapons in this country, as many as 500,000 missile wounds occur annually, resulting in 50,000 deaths, significant morbidity, and striking socioeconomic costs. Wounds are generally classified as low-velocity (less than 2,000 ft/sec) or high-velocity (more than 2,000 ft/sec). However, these terms can be misleading; more important than velocity is the efficiency of energy transfer, which is dependent on the physical characteristics of the projectile, as well as kinetic energy, stability, entrance profile and path traveled through the body, and the biologic characteristics of the tissues injured. Although bullets are not sterilized on discharge, most low-velocity gunshot wounds can be safely treated nonoperatively with local wound care and outpatient management. Typically, associated fractures are treated according to accepted protocols for each area of injury. Treatment of low-velocity, low-energy fractures is generally dictated by the osseous injuries, as these are similar in many regards to closed fractures. Soft tissues play a more critical role in high-velocity and shotgun fractures, which are essentially open injuries. Aside from perioperative prophylaxis, antibiotics are probably required only for grossly contaminated wounds; however, because contamination is not always apparent, most authors still recommend routine prophylaxis. High-energy injuries and grossly contaminated wounds mandate aggressive irrigation and debridement, including a thorough search for foreign material. Open fracture protocols including external fixation or intramedullary nailing and intravenous antibiotic therapy for 48 to 72 hours should be instituted. If there is vascular damage, exploration and repair are best performed after prompt fracture stabilization. Evaluation of the "four Cs"-color, consistency, contractility, and capacity to bleed-provides valuable information regarding the viability of muscle. Skin grafting is preferable when tension is required for wound closure, although other soft-tissue procedures, such as use of local rotation flaps or free tissue transfer, may be necessary, especially for shotgun wounds. Distal neurologic deficit alone is not an indication for exploration, as it often resolves without surgical intervention.

    • Keywords:
    • Algorithms|Bone and Bones|Fractures

    • Bone|Humans|Muscle

    • Skeletal|United States|Wound Infection|Wounds

    • Gunshot

    • Subspecialty:
    • Trauma

The role of human bone morphogenetic proteins in spinal fusion.

The attainment of a stable arthrodesis is critical to the successful management of some types of spinal disorders. Autologous iliac-crest bone graft has been the most commonly utilized substance associated with predictable healing in spinal fusion applications. Although alternative graft substances exist, these have not been shown to be as uniformly effective in achieving spinal fusion. Because of the morbidity associated with bone autograft harvest, there is increasing interest in alternative graft substances and especially in the osteoinductive abilities of bone morphogenetic proteins (BMPs). Several animal models have demonstrated that BMP-containing allograft or synthetic carrier medium is as effective as or superior to autograft bone in promoting spinal fusion. Furthermore, the limited number of human trials utilizing BMPs to treat nonunions in the appendicular skeleton indicate that the results found in animal models will be reproducible in the clinical setting.

    • Keywords:
    • Animals|Bone Morphogenetic Proteins|Fractures

    • Ununited|Humans|Ilium|Lumbar Vertebrae|Recombinant Proteins|Spinal Fusion|Transplantation

    • Autologous|Transplantation

    • Homologous

    • Subspecialty:
    • Spine

Aging successfully: the importance of physical activity in maintaining health and function.

Physicians caring for middle-aged and older patients frequently overlook the importance of regular physical activity. Exercise on a routine basis is an important component of successful aging. It has been shown that many age-related declines in musculoskeletal function can be markedly reduced by participation in some form of regular exercise. Examination of records from masters athletic competitions has been used to determine the true rate of age-related functional declines in highly trained, healthy individuals and further supports these findings. Declines in physical abilities for masters athletes are gradual, which suggests that for many, the potential for participation in competitive athletics can persist well into the seventh decade of life. Recent studies indicate that health gains can be achieved with relatively low volumes of exercise. Indeed, the greatest benefit is seen when one "goes from doing nothing to doing something." Current data suggest that a cumulative total of 30 to 50 minutes of aerobic exercise a day performed 3 to 5 days a week and one set of resistance exercises targeting the major muscle groups twice a week can produce significant health benefits. The aerobic conditioning requirement need not be a formal or structured activity, but can be satisfied through regular participation in many common physical tasks (e.g., walking, gardening, housekeeping). Musculoskeletal injuries are a major cause of noncompliance with any exercise regimen and are especially debilitating for older individuals. Prompt recognition of injury and treatment that emphasizes alternative conditioning exercises and minimizes "downtime" are especially important. Orthopaedists should be aware of the pattern of musculoskeletal injuries seen in this population, so as to assist their patients in avoiding these problems.

    • Keywords:
    • Aged|Aging|Exercise|Humans|Life Style|Middle Aged|Musculoskeletal Physiological Phenomena|Sports

    • Subspecialty:
    • Sports Medicine

    • General Orthopaedics

Evaluation of chronic wrist pain.

Chronic wrist pain remains a challenge to diagnose and treat. A thorough history and physical examination are key. Various imaging techniques are essential to the evaluation of the patient with chronic wrist pain. Standard radiography, computed tomography, cinearthrography, magnetic resonance imaging, radionuclide imaging, arthroscopy, and arteriography all may have a role in assessment, and the orthopaedic surgeon should be familiar with the indications, strengths, and weaknesses of each. Laboratory tests may also be useful in evaluation. No all-inclusive algorithm can be applied in this setting; therefore, the physician must rely on his or her diagnostic acumen to successfully assess and treat chronic wrist pain.

    • Keywords:
    • Arthralgia|Carpal Bones|Diagnostic Imaging|Humans|Physical Examination|Wrist Injuries|Wrist Joint

    • Subspecialty:
    • Pain Management

    • Hand and Wrist

Surgical treatment of metastatic disease of the femur.

Nearly every malignant neoplasm has been described as having the capability to metastasize to bone. Of the estimated 1.2 million new cases of cancer diagnosed annually, more than 50% will eventually demonstrate skeletal metastasis. Advances in systemic and radiation therapy have led to a considerable improvement in the prognosis of patients with metastatic disease. As a result, orthopaedic surgeons are being asked with increasing frequency to evaluate and treat the manifestations of skeletal metastases. The femur is commonly the site of large impending lesions and complete pathologic fractures. Although the health status of some patients may preclude operative intervention, established pathologic fractures of the femur and metastatic lesions deemed likely to progress to imminent fracture generally should be treated surgically. A rational approach to selection of the proper treatment for these problems includes consideration of the patient's overall medical condition and the type, location, size, and extent of the tumor. Treatment principles are the same regardless of location. A construct should ideally provide enough stability to allow immediate full weight bearing with enough durability to last the patient's expected lifetime. All areas of weakened bone should be addressed at the time of surgery in anticipation of disease progression. To minimize disease progression and possible implant or internal fixation failure, postoperative external-beam irradiation should be considered.

    • Keywords:
    • Femoral Fractures|Femoral Neoplasms|Fractures

    • Spontaneous|Hip Fractures|Humans|Weight-Bearing

    • Subspecialty:
    • Musculoskeletal Oncology

Perioperative lower urinary tract infections and deep sepsis in patients undergoing total joint arthroplasty.

Deep sepsis in the involved joint after hip or knee arthroplasty may be the result of hematogenous seeding from a remote infectious source. This mechanism has been used to explain the well-documented association between postoperative urinary tract infections and subsequent joint infection after hip or knee arthroplasty. However, it is unclear whether there is an association between preoperative bacteriuria and deep prosthetic infection. The purpose of this review is to identify perioperative risk factors associated with bacteriuria that have a positive correlation with deep joint sepsis following total hip or knee arthroplasty. The classic symptoms of dysuria, urgency, and frequency seen with urinary tract infections are often absent in the elderly despite the presence of urine coliforms; in these patients, pyuria (as indicated by the presence of more than 1x10(3) white blood cells per milliliter of noncentrifuged urine) may be used as a preliminary screening criterion. If there are irritative symptoms, the presence of more than 1x10(3) bacteria per milliliter of urine should be regarded as indicative of a urinary tract infection. If there is bacteriuria without symptoms of urinary irritation or obstruction, the current literature supports proceeding with total joint arthroplasty and treating those patients with urine colony counts greater than 1x10(3)/mL with an 8- to 10-day postoperative course of an appropriate oral antibiotic. Postponement of total joint surgery should be considered if preoperative evaluation reveals symptoms related to obstruction of the urinary pathway. Irritative symptoms in combination with a bacterial count greater than 1x10(3)/mL should also serve as an indication to postpone surgery. To diminish postoperative urinary tract infection, a bladder catheter should be inserted immediately preoperatively and removed within 24 hours of surgery to diminish the risk of urinary retention, which has been shown to increase the likelihood of a postoperative urinary tract infection.

    • Keywords:
    • Algorithms|Arthroplasty

    • Replacement

    • Hip|Arthroplasty

    • Knee|Bacteriuria|Humans|Postoperative Complications|Surgical Wound Infection|Urinary Bladder|Urinary Tract Infections

    • Subspecialty:
    • Adult Reconstruction