CURRENT Essentials Orthopedics by Harry Skinner, Michael Fitzpatrick

By Harry Skinner, Michael Fitzpatrick

present necessities: Orthopedics -- the last word at-a-glance bedside guide!

  • “Nutshell” info at the prognosis and remedy of the 2 hundred commonest orthopedic ailments and problems
  • One sickness in keeping with web page, with bulleted lists for simple entry
  • Covers all appropriate strategies, from grownup reconstructive surgical procedure to foot and ankle surgical procedure
  • ICD9-CM codes for every subject, permitting you to code and classify morbidity facts after making the prognosis
  • Included in every one subject --Essentials of prognosis --Differential prognosis --Treatment --Pearl --Reference
  • Handy tabs

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Br J Sports Med 2005;39:106. : Intramuscular corticosteroid injection for hamstring injuries. A 13-year experience in the National Football League. Am J Sports Med 2000;28:297. [PMID: 10843118] 44 Current Essentials: Orthopedics Head Injuries in Athletes ICD-9: not applicable ■ Essentials of Diagnosis • Head injuries comprise ~5% of all sports injuries and 19% of football injuries in high school • Injuries can be either diffuse or focal • Diffuse brain injuries have no identifiable lesion; severity can range from diffuse axonal damage with persistent neurologic deficits to concussion • Although focal brain injuries and diffuse axonal injuries can occur in sports, concussions are most common • Principle features of concussion: loss of consciousness (LOC) and amnesia (antegrade, retrograde, or both) • Radiographs and CT scan of the head are the imaging exams of choice to evaluate a head injury ■ Differential Diagnosis • Focal brain injury: subdural hematoma, epidural hematoma, cerebral contusion, intracerebral hemorrhage, subarachnoid hemorrhage • Cervical spine injury • Skull fracture ■ Treatment • Treatment of severe head injury is beyond the scope of this book; if a head injury is suspected, seek immediate evaluation by a properly trained medical professional • Obtain radiographic evaluation with CT in athletes with any neurologic deficit, LOC >5 s, nausea, lethargy, headache, dizziness, or seizure • If neurologic signs or symptoms are absent but the athlete sustained a significant blow to the head, perform serial exams and monitor carefully for 24–48 h after injury ■ Pearl Individuals with an epidural hematoma usually have an initial LOC followed by a period of apparent recovery.

Evaluation and management of valgus impacted four-part proximal humerus fractures. Clin Orthop 2006;442:109. 3 ■ Essentials of Diagnosis • Anterior dislocation is most common, then posterior (50:1) • Anterior dislocation occurs with the arm abducted and externally rotated; posterior, with the arm flexed and internally rotated • Posterior dislocation is less painful than anterior • On physical exam, anterior dislocation produces “fullness” anteriorly and inferiorly; posterior dislocation produces fullness in back, and the coracoid is more prominent • Obtain orthogonal radiographic views (very important, especially with posterior dislocations, to avoid missing the diagnosis); scapular “Y” view, axillary view, and AP and “West Point” views permit visualization of occult fractures ■ Differential Diagnosis • Fracture-dislocation of the humerus • Multidirectional instability ■ Treatment • Closed reduction is indicated, with appropriate sedation and analgesia; gentle traction in line with the arm, using some internal and external rotation with appropriate countertraction, generally reduces the dislocation • The incidence of recurrence is inverse with age and amount of trauma causing the dislocation; older age at time of dislocation and greater trauma causing the dislocation are associated with decreased recurrence rates but with increased incidence of concurrent rotator cuff tears • Immobilization for a short period (1–2 wk) to resolve pain for patients >50 y and for 3–4 wk for younger patients is indicated; the correct length of immobilization and position of immobilization have not been determined • Recurrent dislocation can be treated arthroscopically in many cases ■ Pearl Because the AP radiograph of a posterior dislocation looks surprisingly normal, this diagnosis is missed 60% of the time.

5 Open ■ Essentials of Diagnosis • Incidence is increasing in the over-60 age group • Occurs after trauma (relatively minor in the older age groups) • Classified according to whether the fracture is extra-articular, intra-articular, unicondylar, or bicondylar (Y, T, H, or lambda patterns), or comminuted • Presence of pain, deformity, and swelling • Radiographs are diagnostic ■ Differential Diagnosis • Radial head fracture • Olecranon fracture • Elbow dislocation ■ Treatment • Some loss of motion is likely from stiffness associated with the fracture • Open treatment with internal fixation is almost uniformly indicated for intercondylar fractures; in older, low-demand patients, total elbow arthroplasty is an option to provide good pain relief and early motion • Some physicians advocate the “bag-of-bone” treatment (ie, no fixation and early motion as tolerated) for older, more sedentary and medically ill patients ■ Pearl Casting is the worst treatment for these fractures due to resultant stiffness.

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