Orthopaedics and Trauma最新文献

Infections of the hand and wrist are thankfully rare, but they present esoterically dependent on the specific structures involved. When underappreciated, they lead to delayed or incomplete management and destruction of highly specialized functional anatomy in the hand which results in significant disability. The general signs, symptoms and investigations for infections in the hand mirror infections elsewhere, but the variety of potential spaces in the hand mean there is no single sensitive indicator clinically, biochemically or radiologically. A high index of suspicion and understanding of the anatomy which affects the presentation, progression, treatment and complications of hand infections is required. This review describes the specific anatomy to be aware of to diagnose and manage hand infections completely, and highlights the near universal requirement for surgery to adequately clear infections in the hand.

Fracture-related infection (FRI) is a serious complication that can result in poor outcomes, delayed bone-healing, soft tissue compromise, and prolonged hospitalization. FRI can present in various ways, largely depending on the timepoint after fracture. Management of this condition can be challenging. In this article we consider how to approach this condition and look at the rationale for decision-making in managing cases with complex infection.

Bone and joint infection are commonly associated with disruption of the soft tissue envelope around the skeleton. Respect and consideration must be given to the soft tissue when treating orthopaedic infection as this can be the most challenging part of reconstruction during effective eradication of infection. Failure to plan for soft tissue problems will increase the risk of treatment failure. We describe the role of plastic surgeons and modern approaches to timely and effective joint working to deliver patient-centric care. Reconstructive options for soft tissues are described and the rationale behind our clinical approach.

Trauma of the shoulder encompasses a wide range of potential injuries. The shoulder forms the articulation between the upper limb and trunk, with a close anatomical relationship to the neck and brachial plexus. Acute injuries can have large overlaps of presenting symptoms and many of the special tests we use are imperfect, and must be applied and interpreted in the context of the injury. It is important that a holistic approach is taken to the assessment of acutely injured shoulders in order to ensure injuries are adequately recognized and to guide appropriate further investigations and management. The purpose of this article is to provide a systematic approach to assessment of acute shoulder injuries and summarize the evidence base for special clinical tests that aid in diagnosis.

Trauma to the shoulder girdle has known associations with neurological and/or vascular injury. The presentation of these can be subtle and could potentially be missed, particularly if the clinician does not maintain a high index of suspicion and clinically examine and investigate appropriately. A missed injury could be detrimental for the patient, both increasing morbidity and affecting long-term outcome. This is especially true for neurological injury, in which missing the window for effective reinnervation procedures can have a lifelong negative impact. Nerve injuries can be difficult to classify clinically in the initial stages and it is crucial to know when nerve conduction studies and imaging are useful, and when early nerve exploration is warranted. Injuries to neurological or vascular structures generally benefit from a multidisciplinary approach to achieve the best outcomes. This article describes common nerve and vascular injuries associated with shoulder girdle trauma, along with approaches to assessment, investigation and timely management.

Fractures of the humeral shaft are relatively common and can occur in any age group. The anatomy of the humeral shaft is vital to understand, in order to plan management of these fractures: the relationship of the radial nerve with the humeral shaft in particular, plays an important role in these fractures. Though non-operative measures are employed for humeral shaft fractures routinely, there are some indications for operative management. There remain a variety of operative interventions available to the surgeon, all with associated pros and cons. This review aims to look in detail at the fracture types, the evidence and surgical methods including a discussion about the complications, particularly a radial nerve palsy.

Shoulder joint is the most mobile joint in the human body and is prone to a myriad of traumatic injuries. Imaging is crucial for guiding patient management and the radiological report should cater to the findings that enable the surgeon in decision-making. This pictorial review presents a brief discussion about the pertinent radiological findings, common classification systems and possible complications about the common injuries around the shoulder.

Proximal humerus fractures account for approximately 6% of adult fractures and the incidence of these injuries is increasing. The clinical consequences are significant, with rehabilitation taking several months and many reporting chronic pain following treatment. Several systems are used to classify these injuries. Disruption of the vascular supply to the humeral head is an important consideration. Fracture morphology and other anatomical fracture characteristics may help predict ischaemia and therefore guide management. Non-operative management consists of immobilization and rehabilitation. Surgical management is typically fixation or arthroplasty. There is considerable variation in practice with respect to treatment strategy and rehabilitation protocols. Our evidence-based assessment suggests that early mobilization of conservatively managed fractures may confer an earlier and quicker recovery. Surgery does not appear to provide any functional or quality of life benefit in comparison to non-operative treatment for patients with displaced two-part proximal fractures. Furthermore, surgery has an additional cost and higher complication risk. The use of locking plates does not appear to be superior to locking nails with respect to functional outcomes. The use of proximal humerus arthroplasty in trauma is increasing and there is some suggestion that reverse total shoulder replacement may improve function, pain and range of movement when compared to hemiarthroplasty. The ProFHER 2 trial will compare these two arthroplasty options and evaluate if these methods are more effective than non-surgical treatment.