Instructional course lectures
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Degenerative cervical disk disease is a ubiquitous condition that is, for the most part, asymptomatic. When symptoms do arise as a result of these degenerative changes, they can be easily grouped into axial pain, radiculopathy and myelopathy. While the pathophysiology of radiculopathy and myelopathy is better understood, the source of neck pain remains somewhat controversial. ⋯ The natural history of these conditions suggests that for the most part patients with axial symptoms are best treated without surgery, while some patients with radiculopathy will continue to be disabled by their pain, and may be candidates for surgery. Myelopathic patients are unlikely to show significant improvement, and in most cases will show stepwise deterioration. Surgical decompression and stabilization should be considered in these patients.
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Complex elbow fractures are exceedingly challenging to treat. Treatment of severe distal humeral fractures fails because of either displacement or nonunion at the supracondylar level or stiffness resulting from prolonged immobilization. Coronal shear fractures of the capitellum and trochlea are difficult to repair and may require extensile exposure. ⋯ Articular injury to the radial head is commonly more severe than noted on plain radiographs. Fracture fragments are often anterior. Implants applied to the surface of the radial head must be placed in a safe zone.
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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.
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Compression of the spinal cord and nerve roots caused by spondylotic changes or disk herniations is the most common etiology for cervical myelopathy, radiculopathy, or myeloradiculopathy. Surgical intervention in treating these conditions has been very successful. Anterior approaches to the cervical spine are being used for the treatment of cervical radiculopathy and myelopathy. The technical aspects of anterior diskectomy and corpectomy, methods of fusion, and the use of instrumentation are important treatment considerations.
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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.