Conservative Treatment of Rotator Cuff Injuries - Jeffrey R. Bytomski, DO; Douglass Black, PT, DPT, SCS, ATC, LAT
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Across all ages and activity levels, rotator cuff injuries are one of the most common causes of shoulder pain. The anatomy and biomechanics of the shoulder guide the history and physical exam toward the appropriate treatment of rotator cuff injuries. Rotator cuff tears are rare under the age of 40 unless accompanied by acute trauma. Throwing athletes are prone to rotator cuff injury from various causes of impingement (subacromial, internal, or secondary) and flexibility deficits, strength deficits, or both along the kinetic chain. Most rotator cuff injuries may be treated conservatively by using regimens of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and functional rehabilitation therapy. Injury prevention programs are essential for the long-term care of patients with rotator cuff disease, for primary prevention, and for prevention of recurrent injuries, unless a traumatically torn rotator cuff is present. Surgical management is reserved for refractory cases that have exhausted conservative measures.
Imaging in Evaluating the Rotator Cuff - Roger Lee Cothran, Jr., MD
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Multiple modalities are available for imaging the shoulder, including radiography, arthrography, computed tomography (CT), CT arthrography, ultrasound (US), magnetic resonance (MR) imaging, and MR arthrography. Each of these modalities has advantages and disadvantages in the evaluation of shoulder structures. This article discusses imaging of the rotator cuff of the shoulder with a primary focus on evaluation by MR imaging and MR arthrography.
Rotator Cuff Injuries in the Contact Athlete - Jack F. Otteni, MD; Claude T. Moorman III, MD
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Rotator cuff injuries in contact athletes are typically a result of a different mechanism than that seen with older patients or overhead athletes. This unique mechanism along with the extreme demands of these athletes presents special challenges to the surgeon. Special consideration should be given to in-season rehabilitation to allow the athlete to continue to compete if possible. When this is not possible, or for the out-of-season athlete with a rotator cuff injury requiring surgery, special consideration must be given to obtaining the strongest repair possible. The goal in all aspects of treatment is returning the athlete to full participation safely while minimizing recurrent injury or disability during the recovery process.
Mini-Open Rotator Cuff Repair - George M. McCluskey III, MD; Bryce W. Gaunt, PT, SCS
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Open shoulder procedures require a deltoid release for proper exposure. Arthroscopic techniques have progressed so that minimally invasive techniques give similar outcomes asmore formal open procedures with less risk of morbidity. Arthroscopically assisted open rotator cuff repair offers advantages over open procedures with some diagnostic and decompression performed with the arthroscope. The mini- open technique has more aspects of a cuff repair performed through the arthroscope leaving a few steps to be done open. The modern use of arthroscopic techniques for minimally invasive rotator cuff surgery coupled with advances in rehabilitation is discussed.
Technique for Arthroscopic Rotator Cuff Repair - Joseph Yu, MD; Laurence D. Higgins, MD; Claude T. Moorman III, MD
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Modern arthroscopic tools and techniques have allowed surgeons to operate on a wide variety of injuries using procedures less invasive than traditional open methods. For shoulder surgery in general, and rotator cuff repairs specifically, methods now yield a similar footprint as open procedures with several advantages, including reduced tissue trauma, postoperative pain, swelling, and concern about the deltoid attachment, which should lead to good outcomes.
Demographics of High-Energy Mechanisms of Injury in the Kids Inpatient Database - Brian Leung, MD; Kenneth J. Koval, MD; Brian Carney, MD; Kevin F. Spratt, PhD
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The purpose of this study was to review the relationship of patient demographics to mechanism of injury (MOI). The 2000 Kids Inpatient Database (KID) was used. Logistic regression was used to evaluate the relationship between each MOI relative to other MOIs for each of five identified predictors (age, gender, race, socioeconomic status, geographic region). The KID had 87,795 children with a MOI coded and complete data for all predictors. For motor vehicle accidents, 16- to 20-year-olds were up to 3.72 times more likely to be involved than any other age group, and males were 40% less likely compared with females. For firearm hospitalizations, 16- to 20-year-old black males have significantly higher risk compared with all other identified groups.
A Biomechanical Evaluation of an Interspinous Device (Coflex) Used to Stabilize the Lumbar Spine - Kai-Jow Tsai, MD; Hideki Murakami, MD, PhD; Gary L. Lowery, MD
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A biomechanical study of an interspinous stabilization spinal implant (Coflex) was carried out using eight human lumbar L4/L5 motion segments. Each motion segment was tested in compression, then flexion/extension, then lateral bending, and then axial rotation at five conditions: 1) intact; 2) partial destabilization (by cutting the supraspinous and interspinous ligaments, the ligamentum flavum, the facet capsules, and 50% of the inferior bony facet bilaterally); 3) stabilization with the Coflex device; 4) complete destabilization with total laminectomy; and 5) stabilization with pedicle screws and rods.
Current Concepts in Locked Plating - Robert D. Zura, MD; James A. Browne, MD
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Approaches to internal fixation have become more biologic. Greater emphasis is placed on vascularity and soft tissue integrity. Locked plates, analogous to rigid internal fixators, can provide relative stability favorable to secondary fracture healing. If applied appropriately, they can avoid soft tissue compromise. The key to this new generation of plates is the locking mechanism of the screw to the plate, which provides angular stability and avoids compression of the plate to the periosteum. Favorable biomechanical and clinical results continue to expand the number of appropriate indications for use of locked plating devices, although exact indications for their use have yet to be precisely defined.
Management of Metallic Mercury Injection in the Hand - C. Lamas, MD, PhD; I. Proubasta, MD, PhD; J. Maj´o, MD, PhD
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This case report discusses a patient who injected 20 mL of metallic mercury subcutaneously in his left hand during an attempted suicide. The blood mercury level was 118 µg/L and the urinary mercury level was 43 µg/L, which confirmed the diagnosis of metallic mercury poisoning. A good result was obtained in this patient and the local and systemic toxicity and its management are discussed. A chelation therapy with dimercaprol and early surgical excision of injected material are recommended because this treatment effectively lowers mercury blood levels and controls the local inflammatory reaction. Intraoperative fluoroscopy is useful to confirm the extent of removal.
Ring Removal From a Swollen Finger: A Refined Technique - Wayne B. Venters, MD
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A ring or circular object (wide steel band/nut) impaled on a swollen finger can be most difficult to remove. Likewise, wedding rings in the preoperative setting do not necessarily need to be cut off. This not previously described method uses a Penrose drain to wrap out the finger, an Esmarch or Ace elastic bandage to exsanguinate the extremity, and a constantly inflated surgical tourniquet or blood pressure cuff to keep out any influx of blood while the swollen finger is being decompressed repeatedly with a reapplication of the Penrose drain. The equipment for removal is readily available in all medical offices or emergency departments. This article presents a solution to a common problem.