Acute tendon injuries

Tendon injuries are common and can result in significant impairment of function. This review outlines key principles as well as specific treatments of injury to flexor and extensor tendons in each zone. Technical considerations for tendon repair and cautions are emphasized. New developments from research in the field of tendon repair are highlighted. Rehabilitation is not discussed as this is covered in another chapter.     

(iv) Acute flexor tendon injury and rehabilitation of hand injuries

This article details the anatomy of the flexor tendons of the hand and the treatment when they are severed. The common techniques and pitfalls of flexor tendon repair are discussed along with a broad overview of the rehabilitation following the injury.     

(vi) Flexor tendon injuries

Flexor tendon injuries are a commonly occurring and often challenging injury presenting to hand specialists that require meticulous surgical repair and early post-operative mobilization in order to achieve a successful functional outcome. Historically the methods of repair and post-operative rehabilitation protocols varied greatly between surgeons, and were based largely on individual experience and anecdotal evidence. Over the last three decades, extensive documentation in the literature, including basic scientific research, randomized controlled trials and a Cochrane review has provided evidence detailing improved or beneficial surgical techniques and post-operative rehabilitation protocols, aimed at ultimately improving the patients’ final functional outcome, after a flexor tendon injury.     

(v) Ligament injuries of the hand

Ligamentous injuries of the digital joints of the hand can give rise to significant disability. While many can be managed conservatively, operative treatment is often necessary, particularly in complete ligamentous ruptures and late presenting cases. This article describes the management of the commoner and less common injuries.     

(iii) Osteochondritis

In this article the presentation, pathogenesis, diagnosis and management of osteochondritis dissecans are reviewed and compared with the osteochondroses and avascular bone necrosis.     

(i) The initial management of spinal injuries

Spinal injuries are common and are often associated with other injuries, therefore should always be suspected in the polytrauma victim. Spinal cord injury resulting from trauma can be compounded by errors in handling, therefore the safe handling of the potentially spinal cord injured patient is of paramount importance at all stages preceding and during hospital care. The early detection of spinal injury is possible using a combination of clinical and radiological criteria, whilst safe initial management before transfer to a designated spinal injury unit consists of spinal immobilisation using recommended protocols.     

(iii) Hand infections

Infections of the hand and upper limb present in large numbers to medical practitioners and represent 20% of admissions to hand surgery units. Infection can manifest in many different forms due to differing aetiological insults and the unique anatomical arrangement and compartmentalization within the hand. As a result, the significance and severity of these conditions at presentation are often not appreciated by both patients or medical staff.Prompt recognition and timely institution of appropriate treatment with splintage, elevation, antibiotics, and aggressive surgical intervention when indicated, can prevent permanent impairment, rapidly returning patients to their pre-morbid level of function. Time is particularly important as infection can spread rapidly, irreversibly damaging complex specialized tissues such as synovium and articular cartilage necessary for unrestricted hand function.Despite the advent and development of antibiotics, delay in presentation, diagnosis or treatment still results in increased morbidity and on occasion mortality, disability resulting from pain, stiffness, contracture or amputation.     

(iii) Bearing surfaces

Alternative bearings surfaces to polyethylene have reduced wear and have led to improved patient outcomes, allowing younger and more active patients to be considered for joint replacements. These bearing surfaces have been developed largely as a response to osteolysis and loosening associated with polyethylene particulate debris. This has led to the evolution of various forms of cross-linked polyethylene and to the greater use of hard-on-hard bearings. The use of metal-on-metal led to resurfacing hip replacements and to the use of large head metal-on-metal hip replacements. Although metal-on-metal bearings have a number of theoretical advantages, the release of metal debris and ions from some designs has been catastrophic. In the future new bearing surfaces must be more thoroughly tested pre-clinically and in well-designed clinical series.     

(iii) Proximal ulna fractures

Fractures to the proximal ulna account for only 1% of all fractures. However, appreciation of the pathoanatomy of the different fracture patterns is essential for the treating surgeon. This review discusses the classification, injury patterns, treatment and outcome of fractures to the olecranon, coronoid process and adult Monteggia fracture dislocations.     

(iii) Lateral ankle instability

Ankle sprains are the most common sports-related injury and are caused by forced plantar flexion and inversion. Most involve the lateral ligamentous complex and recover with conservative management, but 20% go on to develop biomechanical or functional instability. This article focuses on clinical symptoms, signs, conservative and surgical management of acute lateral ankle sprains and lateral ankle instability.     

(iii) Cervical spine trauma

Cervical spine trauma frequently accompanies major trauma, and its presence should be assumed until proved otherwise. It is important to recognize whether an injury is stable or not, and if there is instability then stabilization should be achieved either by nonoperative or operative means. This article considers the injury patterns seen in the cervical spine and how these should be evaluated and managed.     

Traumatic dental injuries and Alpine skiing

Abstract – The purpose of this study was to determine the occurrence and type of traumatic dental injuries after maxillofacial injuries as a result of Alpine skiing. During an 8‐year period (from January 1991 to December 1998) 7600 patients with facial injuries were registered at the Department of Oral and Maxillofacial Surgery, University of Innsbruck, Austria. Of 784 patients with skiing‐related facial injuries (524 males, 260 females) 326 (41.6%) sustained injuries to 639 teeth. The age groups predominantly affected were between 7 and 32 years. Luxation injuries occurred in 338 (53%) teeth, fractures accounted for 270 tooth injuries (42%), and only 35 (5%) were lost at the place of the accident. Of skiers with traumatic dental injuries 58% had concomitant soft tissue injuries, while 23.3% had associated facial bone fractures. The most common causes of injury were falls in 42% (329 patients) and collisions with other persons in 24.1% (189 patients). Being hit by one's own sports equipment (11%) was the third most common cause. Collisions with obstacles accounted for 9% and lift accidents for 5.6% of injuries. The probability of suffering dentoalveolar trauma during skiing varied depending on the injury mechanism. There was a 2–fold risk for dentoalveolar trauma when colliding with objects, a 3.5‐fold risk when hit by one's own equipment and a 8.5‐fold risk during lift accidents. Dental injuries occurred in about 2% of all injured skiers. Dental health professionals should be aware of the high incidence and the distribution of dental trauma and facial injuries caused by skiing.     

Primary tooth injuries in Norwegian children (1–8 years)

Abstract –  This prospective study examined the yearly incidence of traumatic injuries to primary teeth. The aim of the study was to find out more about dental injuries to primary teeth in Norwegian children. The study was performed in one county of Norway involving approximately 20 000 children in the age group 1–8 years. Twenty-seven public dental clinics and 42 dentists participated. The dentists attended information and calibration meetings and received illustrations of the classification of dental trauma as well as examples of how to fill in the forms correctly. Two hundred and sixty-six children were involved, including 447 primary teeth, recorded during a 1-year registration period (2003). The dental trauma incidence was 1.3% with 3.5-year old being the most accident-prone. Boys were significantly more often injured than girls, 164 versus 102 ( P  < 0.001). The upper central incisors were most involved (92%), with a non-significant difference between the right and left side. The minor periodontal injuries dominated (59%). Hard tissue injuries were far less frequent (13%). Avulsions were observed in 6.5% and intrusions in 7.5% of the injured children, being 5.5% and 5% of the injured teeth. Most of the injuries occurred either at home (38%) or at kindergarten (32%). Sixty-two percentage were falling accidents often sustained during children's play, and 25% were pure playing accidents.
Conclusion:  In Norwegian children aged 1–8 years, with a predominance of boys, the most common primary tooth injuries were minor luxations of the maxillary central incisors, sustained at an age of 3.5 years. As the traumas often occurred during children's play and/or were the consequence of falls, these are difficult to prevent. However, follow ups should be carried out to disclose pulpal or periodontal complications and/or developmental disturbances of the permanent successors.     

(iii) Patient selection and consent

Appropriate patient selection and consent for a total hip replacement or hip resurfacing is a serious undertaking and one that should not be taken lightly.From the patients’ first presentation, we cover the common pitfalls that can be encountered in the patients’ history and examination as well as specific indications and contraindications to hip resurfacing and hip replacement.Possible alternatives to arthroplasty are discussed ranging from simple analgesia to the more controversial treatments such as hyaluronic acid injections.The different options available for a total hip replacement are considered including the choice of a cemented or uncemented implant, the bearing surface and the reasons for making those choices.Unfortunately hip arthroplasty is not without risk and these potential complications are discussed. The incidence of a lower extremity thrombosis has been quoted as high as 70% but this can be mitigated with thromboembolic prophylaxis. The risk of infection varies from approximately 0.4 to 1.5%.The risk of dislocation between 0 and 2% and fracture less than 1%. Nerve injury can be as high as 3% but is commonly quoted nearer to 1%, and is higher in revision operations at up to 4 %.As well as possible complications, patients should also be made aware of the normal post-operative course from what to expect when they wake up to the type of tests they will have in their immediate post-operative recovery.With the pressures of clinic and operating lists it can be all to easy to rush through these important issues, however, time invested at this stage of the proceedings is well spent.     

(iii) Principles of acetabular fractures

Acetabular fractures are rare, significant injuries involving the articular surface of the acetabulum. They are typically associated with a high-energy mechanism of injury, though fragility type fractures are now increasingly seen. Associated injuries to another organ system are seen in half of all cases. Radiographic assessment is performed using antero-posterior pelvic radiographs and Judet views, as well as computerized tomography (CT). Classification is based on the column theory and describes fracture anatomy in relation to the anterior and posterior columns. Non-operative treatment is indicated when there is less than 2 mm of articular displacement or when patient factors (such as associated injuries/co-morbidities) or soft tissue injury are incompatible with surgery. Open reduction and internal fixation is indicated in displaced fractures, total hip arthroplasty being used in unreconstructable injuries. Operative treatment involves difficult exposures and technically demanding reduction and fixation techniques. Significant associated injuries include neurovascular injury, bleeding, open fracture wounds, soft tissue injury, hip dislocation and femoral fractures. Late complications include post-traumatic osteoarthritis, avascular necrosis and heterotopic ossification. The goals of treatment should be to give the patient a congruent, functional hip whilst minimizing the complications from both the injury and surgery. Poor results are more likely if the reduction is non-anatomical.     

A retrospective study of dento-alveolar injuries

Abstract Traumatic injuries to primary and permanent dentition may lead to severe therapeutic problems. The purpose of the investigation was to evaluate epidemiologic data of dentoalveolar injuries collected in a university dental clinic. The sample consisted of 300 patients (198 boys, 102 girls) representing 480 injured teeth, mostly maxillary incisors (94.6%). The results pointed-out a high predominance of traumatized primary teeth. Types of injuries differed between deciduous and permanent dentition: luxation injuries were most often recorded in primary dentition (81%), while a high percentage of crown and crown-root fractures were recorded in permanent dentition (38%). Epidemiological observations concerning location, etiology and distribution of dento-alveolar injuries are briefly discussed.     

(iii) Fractures of the tibial pilon

Pilon fractures are severe injuries, with potential to cause long term disability. Outcome depends on the soft tissue injury sustained and the quality of skeletal reconstruction. The evolution of management strategies is discussed, based on understanding the anatomy and classification of this heterogeneous group of injuries. They are approached with a view to formulating a safe management plan to minimize complications associated with treatment, whilst optimizing the outcome by careful soft and hard tissue handling.     

(iii) The management of soft-tissue sarcomas

Soft-tissue sarcomas are a heterogeneous group of malignant tumours of connective tissue. The investigation, diagnosis and treatment of these rare tumours should be co-ordinated by specialist multi-disciplinary teams. Here we discuss the surgical principles involved in the management of these tumours, and explore the literature on surgical margins and adjuvant treatment. The management of local and systemic recurrence and prognosis are discussed and the evidence base reviewed.