By D. Felipe. California Institute of Technology. 2018.

In the early phase of the hospital course cheap 1mg finax with mastercard, a large amount of edema fluid from the initial resuscitation will be present purchase 1mg finax amex. In addition cheap finax 1mg mastercard, the surgeons will fre- quently inject dilute crystalloid solution subcutaneously (clysis solution) to facili- tate debridement or harvest of split-thickness skin for autografts proven finax 1mg. Limiting crystalloid used for volume replacement can minimize the volume of extra fluid needed to be eliminated after these procedures. Large amounts of normal saline administered intrave- nously, however, have been associated with hyperchloremic metabolic acidosis. By itself this metabolic derangement is relatively benign, but during resuscitation from major blood loss it can confuse assessment and/or exacerbate effects of acidosis due to poor tissue perfusion. Lactated Ringer’s solution is not associated with such problems, but there is theoretical concern regarding diluting packed red blood cells with lactated Ringer’s solution because of the latter’s calcium content and the potential for formation of thrombi. In our practice, blood loss during burn wound excision is replaced with packed red blood cells reconstituted with plasma. Plasmalyte is added as needed to reduce the viscosity of administered blood or when additional volume is needed but not more oxygen-carrying capacity. This minimizes crystalloid load and helps to prevent coagulopathy due to dilution of coagulation factors. As a rule of thumb, once the blood loss exceeds the estimated total blood volume of the patient, it may be Anesthesia 127 best to avoid further wound excision. In our experience at this point another total blood volume will be lost before the wounds are grafted and dressed. Blood loss in excess of two blood volumes in these patient is associated with increased risk of coagulopathy. Titrating fluid replacement for blood shed during acute burn excision is a difficult task at present. No single monitor or physiological end point will accu- rately reflect volume needs or tissue perfusion. Although mean arterial blood pressure and urine output are most commonly cited as physiological end points for resuscitation of acutely burned patients, abundant data indicate that these variables do not adequately reflect cellular oxygen delivery. In most surgical procedures shed blood is removed from the field by suction and collected in reservoirs where it can be measured. During burn wound excision blood is lost over a potentially broad surface where it can flow under drapes or out through a drain on the table. Since the blood is not collected in a single reservoir or in sponges that can be examined, it is impossible to estimate accurately blood loss intraoperatively. The anesthetist must base evaluations of the patient’s volume status on several physiological variables. Since each of these variables lacks sensitivity, specificity, or both, several monitors of preload and perfusion must be followed and decisions regarding administration of volume are somewhat subjective in these cases. Blood pressure and heart rate change with blood loss but many other causes of decreased blood pressure and increased heart rate during burn wound excision decrease the monitoring value of these variables. Among the confounding factors are anesthetic drugs, pain, and the effects of bacterial products or inflammatory mediators released by wound manipulation. In addition, even though cardiac output and tissue perfusion are reduced by hypovolemia, blood pressure can be maintained by vasoconstriction up to a point. Much information is available from observation of the arterial wave form. The area under the each wave is related to the ejection volume and the slope of the upstroke is influenced by the heart’s contractility. When blood loss exceeds replacement, preload falls and stroke volume is diminished. This is reflected by a reduction in the area under the arterial wave of the arterial blood pressure and a reduction in the pulse pressure. Reduction of contractile force reduces the slope of the arterial wave upstroke. When hypovo- lemia is compensated by intense vasoconstriction, the ejection volume and the area under the arterial wave are still diminished but the waves are tall and narrow. This is because the pressure is maintained by increased afterload and the intense vasoconstriction reduces arterial compliance, leading to an increased pulse pres- sure.

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The examination must be performed slowly and Skeletal deformities steadily in patients with spasticity buy finax 1mg overnight delivery, since sudden move- As well as measuring the range of motion in the joints and ments can trigger spasms which can then be mistaken muscle contractures buy discount finax 1mg line, the orthopaedist must also ascertain for muscle contractures order finax 1mg without prescription. The patient’s position as he or depend on the position of the body generic 1mg finax with visa, while primitive re- she enters the office is particularly informative. Nevertheless, the mobility of the trunk postures are also still present. The spine is examined with the patient in a sitting or In our experience, examinations under anesthesia are standing position. At the In patients with muscular dystrophy, the possibility hip, just shifting the range of motion in the direction of of pain must be taken into consideration in addition to internal rotation will reveal any increased anteversion. Consequently, even slight stretching is tion in which the greater trochanter shows maximum painful. A clinical parameter At the hip level, shortening of the flexors is com- for the torsion in the lower leg is the angle between the pensated for by hyperlordosis since, when the patient is knee axis and the malleolar axis with the knee in a flexed lying down, gravity forces the legs downward, producing position. If the other leg is flexed to its maximum extent, the pelvic tilt and compensatory Functional examination hyperlordosis are cancelled. The thigh of this other leg Any examination should, insofar as possible, include the then raises itself from the examination couch, thereby testing of functions such as walking, standing or sitting demonstrating the presence of a flexion contracture. Full in order to establish the functional consequences of the extension can be examined with the patient in the supine observed structural changes. The analysis of walking in position with the legs hanging freely over the end of the everyday clinical practice is essentially based on the prin- couch. The length of the knee flexors (hamstring muscles) ciples of gait analysis. While a basic clinical examination can readily be evaluated by flexing the leg at the hip by 90° is usually sufficient for a general assessment of simple and then stretching the knee out of the flexed position. Alternatively, the extended leg nature and extent of the functionally disruptive changes can be lifted off the couch and the maximum flexion at – together with details that are important for the treat- the hip measured. Standing on such patients only sink towards the floor to the point one leg for a fairly long period involves a higher degree where the knees press against each other, thus enabling of difficulty. These two tests can provide a rough as- them to stand in a stable position. As well as checking leg length and nally rotated legs: If the knees give way, they do so in the balance of the standing patient, the examiner also assesses direction of walking. But if they give way when pointing whether the hips and knees can be extended sufficiently straight ahead or outwards (as in patients with legs that and whether both legs are weight bearing. Patients with point straight ahead or outwards), the patients must bal- sitting problems of contractures in particular must be ance their upper body over the poorly controllable legs examined while seated. Ideally, the patient should sit on in order to restore their equilibrium. The orthopaedist a trunk-swinging or Duchenne limp that cannot be im- can now test whether the patient is able to maintain this proved by treatment. On the other hand, a pronounced position independently or how much additional external internal rotation during walking can be troublesome if the help with stabilization is required. Actual forward propulsion is no longer possible zontally without rotation, and the legs are spread apart as and walking is hampered. The trunk is aligned as straight as pos- that the aim of treatment is not a »normal« configuration sible over the pelvis in this position. This is a simple way of the musculoskeletal system, but rather one that is best of showing the extent to which movement restrictions for the patient. Examination of the patient legs can also simply be esthetically unappealing without in the lying position should not be forgotten, since these any functional impairment. Hemiplegic patients may dis- patients may lie for relatively protracted periods during like their typical hand position with pronation, flexion the day, and posturally-related deformities are common. A flex- tional deficit must be ruled out in connection with any ion contracture at the knee subsequently leads to flexion surgical correction. The leg is thus drawn up and falls inward or may be of no functional relevance if weight is not placed outward depending on the muscle tone in each case. In these cases the defor- blanket or quilt also exerts a long-term »corrective« force mity is merely of a cosmetic nature, and the patient’s wish through gravity.

While this major destruction of important hip Surgical treatment is indicated if a pronounced func- stabilizers corrects the functional internal rotation in tional leg-length discrepancy results from the abduc- the immediate postoperative period discount finax 1mg with visa, the above-men- tion contracture cheap finax 1mg fast delivery, if there is a risk of subluxation or tioned severe deformity finax 1mg line, which is almost impossible dislocation of the contralateral hip or if severe asym- to correct order 1 mg finax, can develop in the long term. While abduction of up to 20° Structural changes is often perfectly possible in a flexion position, and thus poses no impediment to intimate hygiene, ab- Definition duction with extended hips is much more restricted, Structural deformity of the hip and femur caused by frequently with angles of just 10° –15°. Structural deformities in primarily spastic locomotor disorders Deformity Functional benefit Functional drawbacks Treatment Increased anteversion Stability while standing Knees rub together, feet drag Derotation osteotomy behind Reduced anteversion – – (Rotation osteotomy) Flexion contracture – Squatting position (walking/ Lengthening of hip flexors, standing), hyperlordosis, posterior placement of the muscles windswept deformity inserting at the iliac anterior superior spine after resection of part of the iliac crest Extension contracture – Sitting restricted Proximal lengthening of the hamstrings, reconstruction of the dislocated hip Windswept deformity – Instability while sitting, Splints, correction of bones and hip dislocation soft tissues Hip dislocation – Pain, instability, restricted Joint reconstruction, femoral movement osteotomy (according to Schanz), head resection, soft tissue release 238 3. To achieve this he Rotational deformities of the femur are very common in has to incline the trunk forwards and laterally, producing patients with spastic locomotor disorders. The antever- a Duchenne limp that can be misinterpreted as weakness sion, which is already more pronounced at birth than in of the abductors. The valgus position of the femur is therefore often overestimated on Retroverted hip the AP x-ray as the femoral neck-shaft angle is projected This occurs in the so-called »wind-swept« deformity, but 3 in a very oblique view. The correct view (with just as does not have any functional significance. Treatment: much internal rotation as anteversion) generally shows rotation osteotomy if necessary. Flexion contracture Since the growing skeleton is shaped according to The spasticity of the hip flexors together with the fre- the forces acting on it, it must be assumed that the quent flexed posture of the hips not infrequently leads change produced in the daily transfer of forces between to flexion contractures. The lumbar spine becomes the acetabulum and femur as a result of the locomo- hyperlordosed. Physical therapeutic stretching of the tor disorder is the reason for this rotational deformity. Botulinum toxin osteotomy found that the rotational deformity recurred injections can prove helpful temporarily. Resec- recorded after operations on children over 8 years of tion of the iliac crest and dorsal displacement of the age. As a rule, however, motor control and gait ex- spine is an effective way of treating this contracture. Consequently, we cur- lengthening procedures should therefore be viewed with rently prefer the supracondylar osteotomy fixed with aAO caution. The supracondylar procedure offers the advantage of immediate weight-bearing. As a Extension contracture result, the patient, who is already in a poor training condi- While this deformity is described in the literature, the tion, does not lose further power as a result of postopera- cause in our patients has always been a ventral hip sub- tive immobilization. The increased inward rotation and abnormal ad- duction position do not always interfere with function Windswept deformity to the same extent. While the knees will knock together When hip flexion contractures are present, gravity forces in a patient with good walking ability and thus hamper the flexed knees downward on the side on which the progress, the increased internal rotation may be useful if muscle tone is strongest. Since the patients often remain the patient is only capable of a transfer function or stand- fixed in this position asymmetrical contractures can form ing. When patients with poor body control and impaired accordingly: on the one side there is flexion, adduction balance reactions try and remain upright but then sink and internal rotation, while on the other there is flexion, toward the floor, both legs knock against each other and abduction and external rotation. This just about enables sitting, because the patient tends to fall to the side over such patients to stand. If the knee faces forward, or even the adducted and internally rotated hip. This joint is also outwards, the patients will fall to the floor without this at great risk of dislocation. Possible treatment includes form of support and thus lose the ability tosupport the physical therapy and splints. For these reasons we have ceased our prac- present, the deformity must be corrected by interventions tice of correcting the rotational deformity in the femur on the bones and soft tissues. Radiological investigation If the legs are in external rotation, the patient must An AP view with suspended lower legs generally permits shift his center of gravity in front of the knee in order to effective evaluation of the hip situation. In a case of pronounced anteversion the rotated position The right hip is adducted and appears to have poorer acetabular of the hips is important for the centering: In neutral rotation (top)both coverage than the abducted left hip. However, the lateral acetabular hips appear dislocated, while in internal rotation (bottom) they are epiphysis is pointed on both sides centered (the two x-rays were recorded immediately after each other) Mistakes in the evaluation of the standard AP x-ray ▬ Adduction of the leg appears to aggravate the centering of the hip (⊡ Fig. Other useful views ▬ The Dunn-Rippstein view for the evaluation of an- teversion (although this method is associated with a c wide margin of error, it is effective in clinical prac- tice).

Beautiful faces in pain: Biases and ac- curacy in the perception of pain cheap finax 1 mg with visa. Ethical implications of pain management in a nursing home: A discussion cheap finax 1mg online. Ethical guidelines for investigations of ex- perimental pain in conscious animals generic 1mg finax with visa. International Association for the Study of Pain Ad Hoc Subcommittee for Psychology Curricu- lum buy 1 mg finax overnight delivery. Pain and cognitive status in the institutionalized elderly: Perceptions and interventions. Randomized control trial of a community-based psychoeducation program for the self-management of chronic pain. The effect of disability claimants’ coping styles on judgments of pain, disability and compensation. The codes of ethics of the Canadian Psychological Association and the Canadian Medical Association: Ethical orienta- tion and functional grammar analysis. The tragedy of dementia: Clinically assessing pain in the confused, non- verbal elderly. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. Inadequate pain management and associated morbidity in children after tonsillectomy. Declaration of Helsinki: Recommendations for guiding doc- tors in clinical research (rev. Ethical guidelines for investigations of experimental pain in conscious animals. Distilling a vast wealth of the author’s experience in this area, the book provides a user-friendly, concise, and readable account of all the main pediatric orthopedic complications, with the addition in this new edition of helpful “pearl” boxes to highlight salient features of the given disorder. A new chapter on the genetics of these disorders provides additional useful background. The new edition is also richly illustrated throughout with many new radiographs and line drawings to supplement the text. Written specifically for residents and attending physicians in pediatrics and family practice, this volume will help doctors provide the optimal care for these patients. He is also Professor of Orthopaedics at the Northeastern Ohio Universities College of Medicine. Children’s Hospital Medical Center of Akron AK, Ohio, USA Northeastern Ohio Universities College of Medicine – Rootstown, Ohio, USA Assistant Editor Kerwyn Jones, M. Children’s Hospital Medical Center of Akron AK, Ohio, USA Northeastern Ohio Universities College of Medicine – Rootstown, Ohio, USA cambridge university press Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge cb2 2ru, UK Published in the United States of America by Cambridge University Press, New York www. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published in print format 2004 isbn-13 978-0-511-18477-2 eBook (NetLibrary) isbn-10 0-511-18477-8 eBook (NetLibrary) isbn-13 978-0-521-82564-1 hardback isbn-10 0-521-82564-4 hardback Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. To my wife, Phyllis Ann Weiner, whose unfailing patience, understanding, support, and sacrifice has fostered its genesis, and to our children, Scott, Tracy, Brad, Kristin, Timothy, Sherri and Romy. Ian Macnab, my revered mentor, the catalyst and stimulant of this effort, for the years of his scholarly advice and the brilliance of his teaching. Odell, my esteemed training chief; and to my parents, Milt and Adeline, for the nurturing that allowed this to take form and shape, and especially my mother Adeline, the most loving and lovable person I have ever known. Contents Listofcontributorspagexi Foreword xiii Preface to first edition xv Preface to second edition xvii Acknowledgments xviii 1 Basic considerations in growing bones and joints 1 The growth plate 1 The epiphysis, metaphysis, and diaphysis 3 Nutrition of bone 4 Responses to stress 5 Contributions to longitudinal growth 5 Skeletal maturation concepts 7 2 Lower extremity developmental attitudes in infancy and early childhood 9 Normal attitudes of the lower extremities (birth to 18 months) 9 Out-toeing 10 Genu varum (“bowlegs”) and genu valgum (“knock-knees”) 12 Metatarsus adductus 13 Metatarsus adductovarus 14 Internal tibial torsion 15 Developmental femoral anteversion (“hip in-toeing”) 17 Flexible calcaneovalgus feet 19 Congenital curly toes 20 Contents viii 3 Common orthopedic conditions from birth to walking 23 Developmental displacement of the hip 23 Congenital idiopathic clubfoot 28 Congenital muscular torticollis 30 Congenital and infantile scoliosis 31 Birth palsies (brachial plexus injuries) 33 Septic arthritis of the hip 35 Congenital vertical talus 38 Congenital hammer toes 39 Congenital overlapping fifth toe 39 Supernumerary digits 40 Trigger thumb 40 Congenital bowing of the tibia 41 Juvenile amputee – congenital types 43 4 From toddler to adolescence 47 Idiopathic “toe-walking” 47 Juvenile myalgia (“growing pains”) 47 The flexible pronated foot (“flexible flatfoot”) 49 Transient (toxic) synovitis of the hip in children 52 Legg–Calve–Perthes disease´ 54 Osteomyelitis 57 Septic arthritis 61 Disc space infection 62 Juvenile rheumatoid arthritis 64 Non-physiologic bowlegs 67 Juvenile idiopathic scoliosis 69 Popliteal cysts (ganglions) 70 Spastic torticollis 71 Subluxation of the radial head 72 Muscular dystrophies 73 Kohler’s disease¨ 76 Discoid meniscus 77 5 Adolescence and puberty 79 Idiopathic adolescent scoliosis 79 Scheuermann’s disease 81 Backache and disc disease 83 ix Contents Spondylolisthesis 87 Slipped capital femoral epiphysis 88 Juvenile–adolescent bunions 91 Peroneal spastic flatfoot – tarsal coalition 92 Recurrent subluxation (dislocation) of the patella 94 Pain syndromes of adolescence 95 Patellofemoral pain syndrome 95 Osgood–Schlatter’s disease 97 Infrapatellar tendinitis (“jumper’s knee”) 99 Calcaneal apophysitis (Sever’s disease) 100 Accessory navicular (chronic posterior tibial tendinitis) 101 Peroneal tendinitis 102 Anserine bursitis 103 Fabella syndrome 104 Osteochondritis dissecans 105 Periostitis (“shin splints”) 107 Rotator cuff tendinitis of the shoulder 109 Epicondylitis (“tennis elbow”) 110 Iliotibial band syndrome (“snapping hip”) 110 Freiberg’s infraction 111 “Ingrown” toenails 112 “Pump bumps” 113 de Quervain’s disease 114 6 Miscellaneous disorders 115 The limping child 115 Leg length discrepancy 118 Arthrogryposis multiplex congenita 121 Cerebral palsy 123 Myelomeningocele (myelodysplasia) 125 Sprengel’s deformity 126 Klippel–Feil syndrome 127 Congenital dislocation of the radial head 128 Congenital radio-ulnar synostosis 129 Congenital absence of the radius 130 Congenital coxa vara (developmental coxa vara) 131 Congenital pseudoarthrosis of the clavicle 132 Osteogenesis imperfecta 133 Contents x Neurofibromatosis (Von Recklinghausen’s disease) 134 Fibrous dysplasia 135 Hemangiomatosis and lymphangiomatosis 136 Osteochondroma (osteochondromatosis) 137 Enchondroma and enchondromatosis (Ollier’s disease) 139 Unicameral bone cyst 140 Aneurysmal bone cyst 141 Non-ossifying fibroma (metaphyseal fibrous defect) 141 Osteoid osteoma 142 Histiocytosis X 144 Malignant soft tissue and bone lesions 145 Rhabdomyosarcoma 146 Synovial sarcoma 147 Ewing’s sarcoma 147 Osteosarcoma 148 7 Genetic disorders of the musculoskeletal system 149 General considerations 149 Achondroplasia 150 Mucopolysaccharidoses 152 Down syndrome 154 Marfan syndrome and homocystinuria 155 Nail–patella syndrome 157 Index 159 Contributors Scott D. Director of Resident Education and Assistant Chairman of Orthopaedics, Division Chief of Oncology, Summa Health Systems-Akron, Ohio, USA Consultant Pediatric Orthopaedics Oncology, Children’s Hospital Medical Center of Akron-Akron, Ohio, USA Associate Professor of Orthopaedic Surgery, Northeastern Ohio Universities College of Medicine – Rootstown, Ohio, USA Bradley K. Associate Professor and Director of the Spine Unit, Pennsylvania State University – Hershey, Pennsylvania, USA Adult Spine Consultant, Regional Skeletal Dysplasia Center, Children’s Hospital Medical Center of Akron – Akron, Ohio, USA Staff Orthopaedic Surgeon, Children’s Hospital Medical Center of Akron – Akron, Ohio, USA Assistant Professor of Orthopaedic Surgery, Northeastern Ohio, USA Universities College of Medicine – Rootstown, Ohio, USA Forew ord The style of this book is unique in the medical literature. It is a pleasure to be able to learn while sitting comfortably in an armchair. It describes the child who limps into the office, and answers the question, “What is the cause of this limp, and how should I treat it? These sections are crucial because they point out the difference between adult orthopedics and pediatric orthopedics.

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