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By Z. Innostian. Greensboro College.

The outstanding osteogenic potential of the ▬ Open fractures or fractures with threatened penetra- periosteum leads to rapid consolidation and im- tion buy dapoxetine 30 mg on line. Medial fractures are rare and represent epiphyseal separa- Pathological fractures purchase dapoxetine 90mg with mastercard. We prefer internal fixation with a small-fragment plate Treatment fixed to the clavicle from the bottom buy dapoxetine 30 mg visa. Conservative Medial epiphyseal separations with retrosternal dislo- cation require emergency reduction buy generic dapoxetine 90mg online, usually as an open! Displaced fractures with an ad latus deformity and short- All that is required for treating the pain dapoxetine 30 mg without prescription, therefore, is ening result in a distinct bony bulge, which is often even immobilization in a simple arm sling for 2 weeks in com- more accentuated at a later stage as a result of marked bination with oral analgesics for 3–4 days. Both the bulging and the shortening after a figure-of-eight strap and an arm sling are identi- remodel themselves if the growth plates are still open, cal. Depending on the severity of the symptoms, arm- although this takes from 6–12 months. Informing the par- hanging exercises may be initiated independently after ents and the patient accordingly will prevent additional just 1–2 weeks. For initially displaced fractures, an x-ray consultations and unnecessary corrective procedures. Apart from the few cases resulting from birth trauma, these fractures occur mainly in over 10-year olds. A conservative approach with early functional mal humeral epiphyseal plate, which appears roof-shaped therapy is particularly suitable for fractures of the from the front and flat from the side. However, such differences are of no Diagnosis therapeutic importance, and very rarely of any prog- Clinical features nostic significance, since relevant growth disturbances Pain in the area of the proximal humerus. The hyperextension traumata lead to tilting in the Imaging investigations dorsal direction, but rarely to instability. Depending on the forced posture Epiphyseal fractures (Salter types III and IV) and avulsion produced by the pain, the proximal humerus may not ap- fractures of the lesser tubercle are rare, as are subcapital pear to be affected from the front on the AP view or from fractures in combination with glenohumeral dislocation a strictly lateral position on the Y view. Ad latus deformities by the full shaft width and shortening of up to 2 cm. Comprehensive briefing of the parents and patient about the biological and chronological processes of spontaneous remodeling of untreated deformi- ties is very important in order to avoid unnecessary »medical tourism« or even surgical interventions. Conservative After 1 or 2 weeks of immobilization in an arm sling or, if the condition is painful, in a Gilchrist bandage, the patient is given instruction on mobilizing the shoulder indepen- dently with active and passive arm-hanging exercises. Operation Closed reduction a b Although rarely indicated, a reduction under anesthetic is ⊡ Fig. Radiographic diagnosis of proximal humerus: AP and usually appropriate if there is unacceptable angulation in lateral: If the elbow is not x-rayed at the same time it can sometimes a dorsal direction and a varus position. The reduction ma- be difficult to differentiate between the AP and lateral planes on the neuver consists of traction, abduction, flexion and slight x-rays of the proximal humerus. If the fracture reduction appears stable serves as a pointer: On the AP view it shows a tent-shaped elevation (a), on the lateral view it appears straight and runs at right angles to under the image intensifier, the follow-up treatment is the the shaft (b) application of a Gilchrist bandage for 2 weeks. The possibility of child abuse must be ruled out particularly in under 3-year olds. Humeral fractures account for almost two-thirds of all acute fractures discovered in cases of child abuse. Most humeral shaft fractures however are seen in adolescents, particularly as a result of direct trauma in sports-related and traffic accidents. Treatment of displaced fractures of the proximal humerus at the age of >12 years: The diagnosis usually readily confirmed by clinical ex- If the situation is unstable after closed reduc- amination (pain, swelling, deformity). Careful identifica- tion in patients older than 12 years of age tion and documentation of the neurovascular status is and an unacceptable degree of displacement essential. Radial nerve and, rarely, ulnar nerve palsies is present (>20°), it is advisable to stabilize occur in approx. In a case of a nerve palsy, we simply monitor the spontaneous course over 6–8 weeks. Recovery can be expected in over 80% of cases as these usually only Closed reduction and stabilization involve neurapraxia.

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Microbiological Pseudocystic buy discount dapoxetine 90mg online, blood-filled cavities are also not neces- investigations should be arranged if osteomyelitis is sarily synonymous with the diagnosis of an aneurysmal suspected dapoxetine 60 mg with mastercard. The possibility of callus-like quired therapeutic procedures be implemented on new bone formation with superimposed microfractures site? For these reasons order 90mg dapoxetine, the tentative The answer to this question is of crucial importance histological diagnosis should always be checked against to the subsequent outcome generic dapoxetine 30 mg on-line. If any discrepancies arise between diagnostic and therapeutic experience buy 30 mg dapoxetine, irreparable the radiological and the histological diagnosis, and if mistakes that impair the prognosis can be made even these are not satisfactorily resolved in the interdisciplin- at the biopsy stage. Consequently, the decision as to ary discussion, even including one with experienced spe- whether the patient can subsequently be treated on cialists, a further biopsy should be performed, possibly in site or will need to be transferred to a specialist hospi- a center with corresponding diagnostic and therapeutic tal must be made before the biopsy. Remarks on the biopsy procedure If the differential diagnostic alternatives are clear and the 4. The surgeon Once the diagnosis has been confirmed, the overall situa- should collect a sufficiently large tissue sample – approx. The usual staging system for tu- the periphery to the center of the tumor. The pathologist must possess pre- not involved (since they are rarely affected) and, on the cise knowledge, on the basis of the x-ray, of the biopsy site. For these reasons Enneking as possible (ideally under frozen section conditions) and has introduced a separate staging system for bone tu- forwarded for further investigations. Imprint cytology can mors that takes account of the following parameters: be used to prepare unfixed biopsy material and samples the histological differentiation grade (G), shock-frozen for additional investigations (see above). A the anatomical situation of the tumor (T) frozen section diagnosis is then required only if it involves (i. As a rule, all In principle, a bone tumor becomes extracompartmental 594 4. Metastases are either not detectable (M0) or Like bone tumors, soft tissue tumors must also be staged. Ac- Apart from the histological differentiation grade (G), the cordingly, benign tumors can be divided into three stages anatomical situation of the tumor (T) – i. Staging of the tumor enables the orthopaedist to presence of metastases, the regional lymph nodes should decide on the appropriate treatment ( Chapter 4. Staging of malignant soft tissue tumors according to the UICC Staging System Stage Histological differentiation Anatomical situation Lymph nodes Metastases (= M) (Grade = G) (Site = T) (Nodes = N) IA G1 (differentiated) T1a/b (≤5 cm) N0 (none) M0 (none) G2 (moderate) T1a/b (≤5 cm) N0 (none) M0 (none) IB G1 (differentiated) T2a (>5 cm) N0 (none) M0 (none) G2 (moderate) T2a (>5 cm) N0 (none) M0 (none) IIA G1 (differentiated) T2b (>5 cm) N0 (none) M0 (none) G2 (moderate) T2b (>5 cm) N0 (none) M0 (none) IIB G3 (dedifferentiated) T1a/b (≤5 cm) N0 (none) M0 (none) G4 (dedifferentiated) T1a/b (≤5 cm) N0 (none) M0 (none) IIC G3 (dedifferentiated) T2a (>5 cm) N0 (none) M0 (none) G4 (dedifferentiated) T2a (>5 cm) N0 (none) M0 (none) III G3 (dedifferentiated) T2b (>5 cm) N0 (none) M0 (none) G4 (dedifferentiated) T2b (>5 cm) N0 (none) M0 (none) IV G1–4 T1–2 N1 (present) M0 (none) G1–4 T1–2 N0/1 (±) M1 (present) 595 4 4. Foukas A, Deshmukh N, Grimer R, Mangham D, Mangos E, Taylor S ⊡ Table 4. Tumor staging in the UICC system (2002) Stage-IIB osteosarcomas around the knee. J Bone Joint Surg Br 84: 706–11 Stage Size and anatomical situation of the tumor 5. Hefti FL, Gächter A, Remagen W, Nidecker A (1992) Recurrent giant-cell tumor with metaplasia and malignant change, not as- T1a Tumor diameter ≤5 cm, no infiltration of the fascia sociated with radiotherapy. J Bone Joint Surg (Am) 74: 930–4 T1b Tumor diameter ≤5 cm, with infiltration of the fascia 6. Hefti F, Jundt G (1994) Welche Tumoren können in der Epiphyse entstehen? Eine Untersuchung aus dem Basler Knochentumor- T2a Tumor diameter >5 cm, no infiltration of the fascia Referenzzentrum. Hefti F, Cserhati M, Dutoit M, Exner GU, Ganz R, Kaelin A (1999) Was T2b Tumor diameter >5 cm, with infiltration of the fascia tun bei einem »Bollen« am Bein? Schweiz Aerztez 26: 1625–8 shows the staging system of the Standardization Commit- 8. Kransdorf MJ, Sweet DE, Buetow PC, Giudici MA, Moser RP Jr (1992) Giant cell tumor in skeletally immature patients. Radiology tee of the International Union Against Cancer (formerly 184: 233–7 the »Union Internationale contre le Cancer« UICC) [14, 9. Since it includes tumor size it is slightly more precise lesions of bone from radiographs. Radiology 134: 577–83 than that of the American Joint Committee on Cancer 10. Mankin HJ, Mankin CJ, Simon MA (1996) The hazards of biopsy, Staging (AJCC), which is also commonly used. Noria S, Davies A, Kundel R, Levesque J, O’Sullivan B, Wunder J, Bell sification of the anatomical situation of the tumor (T) in R (1996) Residual disease following unplanned excision of a soft- the UICC system is shown in ⊡ Table 4. J Bone Joint Surg (Am) 78: 650–5 Staging is a valuable aid in establishing the therapeutic 12.

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L a t p l a n t a r P l a n t a e s u r f a c e o f c a l c a n e u s f l e x o r d i g i t o r u m l o n g u s d i g i t s I I t o V a discount dapoxetine 60 mg on-line. M e d d i g i t o r u m l o n g u s i n t e r o s s e i i n t o b a s e s o f / I P j o i n t s D e e p l a t p l a n t a r a purchase dapoxetine 90 mg on line. I I t o V K e y f l e x i o n M i n = m i n i m a l / e x t e n s i o n M T P = m e t a t a r s a l p h a l a n g e a l r o t a t i o n M C P = m e t a c a r p a l p h a l a n g e a l ▼ d e p r e s s i o n purchase dapoxetine 30 mg online, d o w n w a r d cheap dapoxetine 90mg visa, c a u d a l I P = i n t e r p h a l a n g e a l ▲ e l e v a t i o n buy dapoxetine 60 mg with amex, u p w a r d , c e p h a l i c P I P = p r o x i m a l i n t e r p h a l a n g e a l o u t w a r d , e x p a n d D I P = d i s t a l i n t e r p h a l a n g e a l n. P e r i p h e r a l N e r v e S e n s o r y A r e a M a n u a l M u s c l e T e s t ( s e e F i g u r e s 1 a n d 2 f o r c o m p l e t e l i s t ) A x i l l a r y ( C 5 - 6 ) U p p e r d e l t o i d a r e a D e l t o i d , t e r e s m i n o r M u s c u l o c u t a n e o u s I n t e r i o r a n d l a t e r a l ( C 5 - 7 ) u p p e r a r m B i c e p s b r a c h i i R a d i a l ( C 5 - T 1 ) P o s t e r i o r a r m , d o r s u m T r i c e p s , w r i s t e x t e n s o r s o f h a n d U l n a r ( C 7 - T 1 ) A n t e r i o r / m e d i a l f o r e a r m , U l n a r f l e x i o n , f l e x o r 4 t h a n d 5 t h f i n g e r s d i g i t o r u m p r o f u n d u s f o r l a s t t w o d i g i t s M e d i a n ( C 6 - T 1 ) A n t e r i o r / l a t e r a l f o r e a r m , T h e n a r e m i n e n c e , p r o n a t o r s p a l m e r t h u m b , 1 s t , 2 n d f i n g e r , h a l f o f 3 r d f i n g e r P e r i p h e r a l N e r v e S e n s o r y A r e a M a n u a l M u s c l e T e s t ( S e e F i g u r e s 1 t h r o u g h 5 f o r c o m p l e t e l i s t ) F e m o r a l M e d i a l t h i g h a n d l e g Q u a d r i c e p s S c i a t i c P o s t e r i o r t h i g h a n d l e g H a m s t r i n g s O b t u r a t o r M i d a n t e r i o r t h i g h A d d u c t o r s C o m m o n p e r o n e a l S e e d e e p a n d s u p e r f i c i a l S e e d e e p a n d s u p e r f i c i a l p e r o n e a l p e r o n e a l D e e p p e r o n e a l W e b s p a c e b e t w e e n 1 s t D o r s i f l e x o r s a n d 2 n d t o e s S u p e r f i c i a l p e r o n e a l M e d i a l d o r s a l s u r f a c e E v e r t o r s o f f o o t T i b i a l P o s t e r i o r l e g P l a n t a r f l e x o r s Peripheral Nerve Innervations-Lower Extremity 373 Figure 18-1. A I Diseases, Pathologies, and Syndromes Defined achlorhydria: A condition resulting in the absence of hydrochloric acid in the gastric juice. It is a syndrome caused by the human immunodeficiency virus that renders immune cells ineffective, permitting opportunistic infections, malignancies, and neurologic diseases to develop; it is transmitted sexually or through expo- sure to contaminated blood. Acromegaly (ie, hyperpituitarism) occurs as a result of excessive secretion of growth hormone after normal comple- tion of body growth. It results in increased bone thickness and hypertrophy of the soft tissues due to growth hormone-secreting adenomas of the anteri- or pituitary gland. Adams-Stokes syndrome: A condition characterized by sudden attacks of unconsciousness, with or without convulsions. Addison’s disease: A disease characterized by a bronze-like pigmentation of the skin, severe pros- tration, progressive anemia, low blood pressure, diarrhea, and digestive disturbance. It is due to dis- ease (hypofunction) of the adrenal glands and is usually fatal. Diseases, Pathologies, and Syndromes Defined 379 adhesive capsulitis: Also known as periarthritis or frozen joints, it is characterized by diffuse joint pain and loss of motion in all directions, often with a positive painful arc test and limited joint accessory motions. It is also called shock lung, wet lung, stiff lung, adult hyaline membrane disease, posttraumatic lung, or diffuse alveolar damage (DAD). Alzheimer’s disease (AD): Alzheimer’s disease is a progressive dementia characterized by a slow decline in memory, language, visuospatial skills, personality, cognition, and motor skills. It is a dis- abling neurological disorder that may be character- ized by memory loss; disorientation; paranoia; hal- lucinations; violent changes of mood; loss of the ability to read, write, eat, or walk; and, finally, dementia. It usually affects people over the age of 65 and has no known cause or cure. ALS attacks the upper motor neurons of the medulla oblongata and the lower neurons of the spinal cord. It is characterized by severe weight loss in the absence of physical cause and attributed to emotions such as anxiety, irritation, anger, and fear. It is character- ized by distortion of body image and the fear of becoming fat. The individual does not eat enough to maintain appropriate weight (maintenance of weight 15% below normal for age, height, and body type is indicative of anorexia). Diseases, Pathologies, and Syndromes Defined 381 anterior inferior cerebellar artery syndrome: A stroke-related syndrome in which the principle symptoms include ipsilateral deafness, facial weak- ness, vertigo, nausea and vomiting, nystagmus (or rhythmic oscillations of the eye), and ataxia. Horner’s syndrome ptosis, miosis (ie, constriction of the pupil), and loss of sweating over the ipsilat- eral side of the face may also occur. Pain and temperature sen- sation are lost on the contralateral side of the body. Arnold-Hilgartner hemophilic arthropathy: A condi- tion in hemophilic individuals beginning with soft tissue swelling of the joints, osteoporosis, and over- growth of epiphysis with no erosion or narrowing of cartilage space; leading to subchondral bone cysts, squaring of the patella, significant cartilage space narrowing; and ending in fibrous joint con- tracture, loss of joint cartilage space, marked enlargement of the epiphyses, and substantial dis- organization of the joints. Sinus arrhythmia is an irregularity in rhythm that may be a normal varia- tion or may be caused by an alteration in vagal stimulation. Atrial fibrillation, or involuntary, irregular muscular contractions of the atrial myocardium, is the most common chronic arrhyth- mia; it occurs in rheumatic heart disease, dilated cardiomyopathy, atrial septal defect, hypertension, mitral valve prolapse, and hypertrophic cardiomy- opathy. Ventricular fibrillation, or involuntary con- tractions of the ventricular muscle, is a frequent cause of cardiac arrest. Heart block is a disorder of the heartbeat caused by an interruption in the pas- sages of impulses through the heart’s electrical sys- tem. Causes include CAD, hypertension, myocardi- tis, overdose of cardiac medications (such as digi- talis), and aging. Arteriosclerosis represents a group of diseases characterized by thickening and loss of elasticity of the arterial walls, often referred to as hardening of the arteries. There are 3 types of AMC: contracture syndromes, amyoplasia (ie, lack of muscle formation), and distal arthrogrypo- sis, primarily affecting the hands and feet. Diseases, Pathologies, and Syndromes Defined 383 ascites: An abnormal accumulation of serous (edema- tous) fluid within the peritoneal cavity, the poten- tial space between the lining of the liver, and the lining of the abdominal cavity.

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Organisms isolated after the burn injury are predominantly gram positive cheap dapoxetine 60 mg with amex. Seven days after the injury the burn wounds are colonized by the patient’s endogenous flora cheap dapoxetine 90mg free shipping, predominantly hospital-acquired gram-negative flora purchase 60 mg dapoxetine with amex. Infection is promoted by loss of the epithelial barrier dapoxetine 30mg fast delivery, by malnutrition induced by the hypermetabolic response to burn injury effective 90 mg dapoxetine, and by a generalized postburn suppression of nearly all aspects of immune response. Postburn serum levels of immunoglobulins, fibronectin, and complement levels are reduced, as is the ability for opsonization. Chemotaxis, phagocytosis, and killing function of neutrophils, monocytes, and macrophages are impaired, and cellular immune response is im- paired. This decrease in the immune response explains why bacteria that in normal hosts are not harmful present a high risk to burned patients. The avascular burn eschar is rapidly colonized despite the use of antimicrobial agents. If this bacterial density exceeds the immune defenses of the host, then invasive burn sepsis may ensue. When bacterial wound counts are 105 micro-organisms per gram of tissue, risk of wound infection is great, skin graft survival is poor, and wound closure is delayed. The goals of wound management are the prevention of desiccation of viable tissue and the control of bacteria. Bacterial counts less than 103 organisms per gram of tissue are not usually invasive and allow skin graft survival rates of more than 90%. The isolation of Streptococcus in the wound should be considered an exception to the former, since bacterial counts of less than 103 bacteria per gram of tissue can provoke invasive burn wound infection and should be treated. Great debate still exists regarding the appropriate isolation regimen for burn patients. For decades, burned patients were treated in dedicated burn centers with strict isolation techniques. It is now common knowledge, however, that burned patients do become infected from endogenous gram-negative flora. Cross-contamination among patients is minimal; therefore, the standard practice of strict isolation is no longer needed. In general, barrier nursing and hand washing after every patient contact should suffice to control infection in the burn unit. More strict measures need to be implemented with the appearance of multiple resistant organisms. Studies from several burn centers have laid to rest the idea that prophylactic antibiotics should be given to burn patients. It increases strains of multiple resistant organisms and challenges the posterior management of burn patients. It is advisable to administer antistreptococcal antibiotics in infants and small children for 24–48 h when sur- gery or application of synthetic dressing is considered. Children are often colo- nized by these organisms and are very sensitive to their growth. Perioperative systemic broad-spectrum antibiotics are advised when major surgery is per- formed. The manipulation of large burn wound surfaces produces a significant bacteremia and bacterial translocation in the digestive tract. It is advised to add General Treatment 49 this perioperative prophylaxis, which should be based on endogenous flora sur- veillance and include an antistaphylococcal agent in the acute period. Several studies have shown that burn patients experience sepsis 72 h after surgery if no antibiotics are used during major burn surgery. These agents should only be continued after surgery if evidence of sepsis is confirmed. Bacterial surveillance through routine surface wound and sputum cultures is strongly advised. When patients become septic, cultures are helpful to direct antimicrobial therapy.

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If radicular symptoms are “reproduced” after 70° of flexion order dapoxetine 60 mg amex, the result is more likely to be a false positive dapoxetine 90mg online. If this maneuver reproduces the patient’s pain buy cheap dapoxetine 90 mg, the hip may be the underlying cause of the symptoms generic dapoxetine 60 mg. If this fails to reproduce the patient’s pain quality dapoxetine 90mg, the hip is unlikely to be involved. With the patient still lying in the supine position, perform the Thomas test to assess for tight hip flexors. To perform the Thomas test, have the patient lie in the supine position and flex one hip so that the patient is hugging one knee to the chest. Low Back, Hip, and Shooting Leg Pain 83 flexor, the extended leg (the leg being tested) will lift off the table (Photo 22). If the patient does not have a tight hip flexor, the extended leg will remain flat on the table when the patient hugs the other knee to the chest (Photo 23). Next, test for a sacroiliac joint or hip injury by performing the Faber test. To perform this test (the patient should be supine), place the foot of the involved side onto the opposite knee in a “figure-4” position (thus flex- ing, abducting, and externally rotating the affected hip. If this produces pain in the inguinal region, the hip joint may be involved. Further stress the sacroiliac joint by pushing down on the flexed knee, as well as on the contralateral superior iliac spine. This tests the patient’s gluteus medius, which is innervated by the superior gluteal nerve (pri- marily L5). Next, with the patient still lying on his or her side, test for a tight ili- otibial band by performing Ober’s test. In this test, flex the patient’s hip and knee that are lying on the table (this is done for stability). Then, take the patient’s other leg (the one not in contact with the table) and Photo 24. If the iliotibial band is not tight, the leg will fall to the table (Photo 25). If the iliotibial band is tight, the upper leg will not fall to the table but instead, will remain in the air (Photo 26). This test also places stress on the femoral nerve, and if it invokes paresthesias in the leg, femoral nerve pathology should be considered. If the test is performed with the knee extended, less stress is placed on the femoral nerve. Have the patient roll onto the other side and repeat testing of the hip abductor and Ober’s test. Have the patient lie in the prone position and instruct the patient to extend the hip against resistance (Photo 27). This tests the gluteus maximus, which is innervated by the inferior gluteal nerve (S1). Table 1 lists the major movements of the hip and leg, along with the involved muscles and their innervation. If the patient’s ipsi- lateral hip spontaneously flexes, this is an indication that the rectus femoris is tight (Photo 29). With your patient still in the prone position, passively extend the hip and flex the knee. If this maneuver reproduces shooting leg pain, there may be a radiculopathy involving L2–L4. Table 1 Primary Muscles and Innervation for Hip, Knee, Ankle, and Big Toe Movement Major muscle Primary muscle(s) movement involved Primary innervation Hip flexion Iliopsoas. Hip abduction Gluteus medius and Superior gluteal nerve gluteus minimus. Knee flexion Hamstrings Primarily tibial but also (semimembranosus, peroneal portion of semitendinosus, biceps sciatic nerve femoris). Knee extension Quadriceps (vastus Femoral nerve lateralis, vastus medialis, (primarily L4). Plan Having completed your history and physical examination, you have a good idea of what is causing your patient’s symptoms.

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