Evaluation and management of recurrent anterior shoulder instability.

OBJECTIVE: To present an organized approach to the assessment and treatment of symptomatic recurrent anterior shoulder instability. BACKGROUND: Knowledge of the relevant pathology and pathomechanics serves as an excellent foundation for the clinical examination, rehabilitation, and if necessary, surgical intervention for shoulder instability. DESCRIPTION: An algorithm is presented for the initial evaluation of shoulder instability, ie, history, physical examination, and diagnostic studies, followed by modes of treatment such as rehabilitation, modification of biomechanics, and surgical treatment (arthroscopic versus open). CLINICAL ADVANTAGES: Early identification of shoulder instability allows for the timely introduction of treatment principles that may obviate more invasive operative procedures.

The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum.

This study was done to determine the results of the arthroscopic treatment of osteochondritis dissecans of the capitellum in a young population. A retrospective review of 16 patients (17 elbows) was performed by follow-up examination and radiographs. The average follow-up was 48 months, with a minimum of 24 months. All patients underwent abrasion chondroplasty of the lesion and removal of any loose bodies and osteophytes when present. Postoperatively, the average flexion contracture decreased by 14 degrees, and the average extension contracture decreased by 6 degrees. Two of nine patients gave up participation in throwing sports, and one of five gave up gymnastics. All others returned to their preoperative levels of activity. Radiographs showed some slight residual flattening of the capitellum in eight patients. Two patients required reoperation: one for arthrofibrosis and one for a suspected loose body. The results of this study suggest that arthroscopic abrasion chondroplasty and treatment of any accompanying pathologic lesions in the affected elbow gave good results in most patients. This is a short-term study in a young population. Further follow-up will be needed to determine any long-term problems with this type of treatment. An arthroscopic classification system has also been proposed.

Isolated posterior cruciate ligament injuries. History, mechanism of injury, physical findings, and ancillary tests.

An accurate diagnosis of an isolated PCL injury may be difficult, especially in the acute setting. A detailed history emphasizing the mechanism of injury is crucial as is a careful, complete examination of the knee. Plain and stress radiographs may be helpful in establishing the diagnosis; however, MR imaging is currently the most sensitive ancillary study available to evaluate the integrity of the posterior cruciate ligament. Failure to recognize and treat appropriately an isolated PCL disruption may result in the development of symptomatic irreversible articular surface injury.

Physical examination of the thrower's elbow.

The physical examination of the thrower's elbow presents the clinician with the clinical challenge of differentially diagnosing specific pathologies. The examination should include a thorough history and a well-organized physical examination, which relies on an extensive knowledge of the functional anatomy of the elbow. The components of an elbow examination include inspection/observation, palpation of bony and soft tissues, range of motion assessment, resisted muscle testing (both manual and mechanical), neurologic testing, and special tests. The special tests commonly performed on the thrower's elbow are the Tinel test, tennis elbow sign, ulnar collateral ligament stability testing, valgus extension overload test, and radiocapitella chondromalacia test. Other tests include radiographic examination, such as computerized tomograph arthrogram and magnetic resonance imaging testing. Information presented in this paper will provide the clinician with a systematic and thorough evaluation process for the thrower's elbow.

A biomechanical comparison of intramedullary nailing systems for the humerus.

This study evaluated the rotational and bending stability of three interlocking nail systems in paired cadaveric humeri. The Russell-Taylor Humeral Interlocking Nail, the Seidel Humeral Locking Nail, and the True-Flex Humeral Nail were mechanically tested in torsion and four-point bending. The Russell-Taylor and the Seidel interlocking nails are reamed systems that rely on proximal interlocking screws and distal screws or phalanges respectively for rotational stability. However, axillary nerve damage may result during proximal screw placement, and these systems exhibit low resistance to rotation. The True-Flex intramedullary nail is an unreamed system that relies on cross-sectional geometry to achieve rotational stability. By not relying on interlocking screws for stability, nerve damage associated with the screw placement may be eliminated. However, the results indicate the cross-sectional geometry of the True-Flex nail is not able to provide the same degree of static locking as the Russell-Taylor or Seidel interlocking nails. Humeri implanted with the Russell-Taylor and Seidel nails also had a significantly greater torsional stiffness than the True-Flex nail. As expected, humeri implanted with the Russell-Taylor and Seidel nails also had a significantly greater bending stiffness than the True-Flex nail in both anterior-posterior and medial-lateral bending.