Instructional course lectures
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Knee injuries commonly occur in children and adolescents who participate in athletic activities. Open growth plates, apophyses, and chondroepiphyses are unique to the skeletally immature knee and account for the differences in injury patterns observed in children and adults. An understanding of anatomy and classification as related to treatment and outcome of fractures in the skeletally immature knee is important.
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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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Closed tibial shaft fractures are common injuries that remain challenging to treat because of the wide spectrum of fracture patterns and soft-tissue injuries. Understanding the indications for surgical and nonsurgical treatment of these fractures is essential for good outcomes. Although cast treatment of stable tibial shaft fractures has traditionally been successful and continues to be widely used, recent clinical studies have shown that intramedullary nails may be more advantageous for fracture healing and function than casting. ⋯ Metaphyseal fractures are well suited for plates, although newer intramedullary nail designs provide the option of intramedullary nailing of proximal or distal metaphyseal tibia-fibula fractures. External fixators are well suited for skeletally immature patients with unstable fracture patterns or for patients with unacceptably small intramedullary canals. Interlocking intramedullary nails are the treatment of choice for most unstable tibia-fibula shaft fractures.
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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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Osteoporosis has received heightened attention over the past 2 decades because of its overwhelming cost to society. It is one of the most common diseases affecting both men and women. The key to treatment is early prevention accompanied by modification of risk factors and impact-oriented exercise, optimal medical management with antiresorptive medications, and addressing the complications of this disease such as compression fractures and spinal deformities. ⋯ The surgical treatment of deformities such as kyphosis and scoliosis can be very challenging given the poor bone quality and propensity for instrumentation cutout. The surgical treatment of spinal stenosis in the face of deformity in these patients requires keen surgical planning and a clear identification of the source of the patient's complaints--be it the deformity, the stenosis, or both. Several advances in instrumentation, such as the use of laminar fixation (if available), multisegment fixation, limited correction of the deformity, and augmentation of pedicle screw purchase through biologic and nonbiologic fillers have been developed.