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Cardiac involvement is uncommon and probably accounts for the continuing ambulatory status generic premarin 0.625mg with mastercard. Far less commonly encountered is limb-girdle dystrophy order 0.625 mg premarin with visa, an autosomal recessive dystrophy order 0.625 mg premarin amex. The diagnosis is generally not established until the second or third decade purchase 0.625mg premarin with amex. It is a slowly progressive disease primarily involving the pelvic and shoulder girdles, with rare pseudohypertrophy in the calf. It is generally differentiated from pseudohypertrophic muscular dystrophy by the late onset, the more benign pattern, and only slight elevation of the creatine kinase level. Another uncommon form of muscular dystrophy seen in the later part of the first and second decade is facio-scapulo-humeral From toddler to adolescence 76 dystrophy, an autosomal dominant disease. Characteristically the muscles of the shoulder girdle and face are affected, and it is a slowly progressive disorder. Clinical findings include muscle weakness, inability to close the eyes tightly, “pouting” of the lips, and absent facial wrinkles. Muscle biopsy demonstrates a dystrophic type pattern with very large muscle fibers and an inflammatory response. Interestingly the creatine kinase levels are usually within normal limits. An awareness of developmental delays and maturation should alert one to formally examine for any areas of muscle weakness. Once the diagnosis has been established, the needs of the patient are directed to the cardio-respiratory status combined with appropriate orthopedic management and physical therapy. Orthopaedic procedures of the spine, hip, knees and ankle level may occasionally delay the transit into a wheelchair and may also improve the quality of life, particularly in regard to the management of scoliosis by early spinal stabilization of progressive scoliosis. Recent use of corticosteroids has shown promise but long-term evaluation remains necessary. Ko¨ hler’s disease Kohler’s disease is a nutritional disorder of the¨ tarsal navicular that results in an avascular necrosis. It nearly always makes its appearance between the age of three and seven years, and is somewhat more common in males. The child presents with an antalgic limp with pain localized on compression in the area of the 77 Discoid meniscus (a) tarsal navicular. The diagnosis is established by a combination of symptomatology coupled with a radiographically fragmented, irregularly dense appearance to the tarsal navicular (Figures 4. The tarsal navicular does not begin to ossify until roughly age three and often may be irregular and fragmented as a normal variation in its ensuing ossification pattern. The diagnosis of Kohler’s disease should be¨ established only when there is a combination of radiographic findings and localized symptomatology. Treatment consists of short-term casting and perhaps brief periods of diminished weight bearing. The prognosis is uniformly excellent with symptomatology disappearing generally within several months after its appearance. Discoid meniscus Discoid meniscus is usually seen between one and eight years of age although occasional cases have been seen under one year of age. A child with a discoid meniscus commonly will present with a complaint of a “clunk” or a “clicking” sensation in the knee with or without (b) discomfort. Occasionally “falling” or reluctance to move the knee through a range of motion is observed. On examination, a characteristic “clunk” or “snap” is perceived on moving the knee through a range of flexion and extension. The clinical findings are most commonly directed to the lateral compartment of the knee and the lateral joint line. The basic pathoanatomy is the presence of a discoid-shaped meniscus rather than the Figure 4.

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Protect patient from harming self or others Place patient in a floor bed with padded side panels (Craig bed) Assign 1:1 or 1:2 sitter to observe patient and ensure safety Avoid taking patient off unit Place patient in locked ward 3 discount premarin 0.625 mg visa. Reduce patient’s cognitive confusion One person speaking to patient at a time Maintain staff to work with patient Minimize contact with unfamiliar staff Communicate to patient briefly and simple discount 0.625 mg premarin overnight delivery, one idea at a time 4 0.625mg premarin visa. Tolerate restlessness when possible Allow patient to thrash about in floor bed Allow patient to pace around unit with 1:1 supervision Allow confused patient to be verbally inappropriate (Reprinted with permission from Braddom RL buy 0.625mg premarin overnight delivery. The use of a floor bed with one-to-one supervision and with the use of mitts and a helmet (if necessary) often eliminates the need for restraints. If nerve is completely involved or transected, patient will develop complete blindness (pupil dilated, unreactive to direct light but reactive to light stimulus to the opposite eye (consensual light reflex) Endocrine Complications Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) Water retention resulting from excessive antidiuretic hormone (ADH) secretion from the neurohypophysis secondary to multiple causes including head trauma In SIADH, ADH excess considered to be inappropriate because it occurs in the presence of plasma hypo-osmolality In SIADH, Na+ excretion in the urine is maintained by hypervolemia, suppression of the renin-angiotensin-aldosterone system, and ↑ in the plasma concentration atrial natriuretic peptide (usually > 20 mmol/L) Common Causes of SIADH CNS Diseases Malignancy – Thrombotic or hemorrhagic events – CA of the lung (especially small cell CA) – Infection – GI malignancy (e. Comparison of SIADH, CSW and DI SIADH DI CSW syndrome Serum ADH (rarely done ↑ (inappropriately (appropriately as routine lab work) elevated) elevated) Diagnostic Labs Serum Na+ Serum osmolality Extracellular volume Normal (isovolemic) Normal (isovolemic) Reduced (hypovolemic) Urine osmolality and SG ↑ (concentrated urine ↓ Normal with osmolality usually > 300 mmol/kg) Spasticity Disorders of motor tone (e. This condition has been termed postconcussive syndrome (PCS) In a recent study, 14 mild TBI patients with unusually persistent deficits evaluated with single photon emission computed tomography (SPECT) showed significant anterior mesial temporal (lobe) hypoperfusion and less striking dominant (left) orbitofrontal abnormalities Memory and learning deficits have been associated with lesions at the hippocampus and related structures in the medial temporal lobes or with injuries to structures that control attention, concentration, and information processing in the frontal and temporal lobe Pharmacologic intervention may be used including antidepressants and psychostimulants Concussion/Sports Related Head Injuries Classification of concussion is controversial The most widely used grading systems for concussion/mild head injury are the Colorado and the Cantu guidelines TABLE 2–14. Cantu and Colorado Head Injury Grading Systems Grade Cantu Colorado Grade I—mild No LOC No LOC PTA < 30 min Confusion w/o amnesia Grade 2—moderate LOC < 5 min No LOC PTA > 30 min Confusion with amnesia Grade 3—severe LOC > 5 min LOC PTA > 24 hrs LOC = loss of consciousness PTA = posttraumatic amnesia (Cantu, 1992) (Report of the Quality Standards Subcommittee, 1997) 78 TRAUMATIC BRAIN INJURY Return to Play Guidelines Return to play criteria have been similarly controversial Colorado Medical Society and Cantu Guidelines are among the most widely used. Cantu’s Guidelines for Return to Play after Concussion Grade First Concussion Second Concussion Third Concussion Grade I— May return to play if May return to play in 2 Terminate season, although mild asymptomatic for 1 week weeks if asymptomatic for patient may return to play 1 week next season if asymptomatic Grade 2— May return to play after Minimum of 1 month Same as above moderate asymptomatic for 1 week out of competition, may return to play then if asymptomatic for 1 week and consider termination of season dependent on symptoms Grade 3— Minimum of 1 month, Terminate season, although severe may return to play if may return to play next asymptomatic for 1 week season if asymptomatic (Cantu , 1998) The American Academy of Neurology endorsed the Colorado Medical Society Guidelines for classification and management of concussion in sports in its Report of the Quality Standards Subcommittee Practice Parameter published in Neurology, 1997. When to Return to Play—Colorado Medical Society Guidelines Grade Return to play only after being asymptomatic with normal of Concussion: neurologic assessment at rest with exercise: Grade 1 concussion 15 minutes or less Multiple Grade 1 concussions 1 week Grade 2 concussion 1 week Multiple Grade 2 concussions 2 weeks Grade 3—brief loss of 1 week consciousness (seconds) Grade 3—prolonged loss of 2 weeks consciousness (minutes) Multiple Grade 3 concussions 1 month or longer, based on decision of evaluating physician (Report of the Quality Standards Subcommittee, 1997) TRAUMATIC BRAIN INJURY 79 REFERENCES American Congress of Rehabilitation Medicine. Recommendations for use of uniform nomenclature pertinent to patients with severe alterations in consciousness. Relative prognostic value of best motor response and brain stem reflexes in patients with severe brain injury. Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation. Practice Parameter: Antiepileptic drug treatment of posttraumatic seizures. Deep venous thrombosis: Incidence on admission to a brain injury reha- bilitation program. Neurobehavioral effects of phenytoin in pro- phylaxis in post-traumatic seizures. Posttraumatic amnesia as a predictor of outcome after severe closed head injury. Amphetamine, haloperidol, and experience interact to affect rate of recovery after motor cortex injury. Pharamcologic modulation of recovery after brain injury: A reconsideration of diaschisis. Head injury with and without hospital admission: comparisons of incidence and short-term dis- ability. Monitoring rate of recovery to predict outcome in minimally responsive patients. Demographic and social characteristics of the traumatic brain injury model system database. Reliability and validity of the Disability Rating Scale and the Levels of Cognitive Functioning Scale in monitoring recovery from severe head injury. Assessment and treatment of cognitive deficits in brain-damaged individuals. The 1994 Multi-Society Task Force consensus statement on the Persistent Vegetative State: a critical analysis. Predicting course of recovery and outcome for patients admitted to rehabilitation. National Institute on Disability and Rehabilitation Research, Traumatic Brain Injury Model Systems Program. Sensorimotor functions, intelligence and cognition, and emotional status in subjects with cerebral lesions. Practice parameter: the management of concussion in sports (summary statement). Rehabilitation of the Adult and Child with Traumatic Brain Injury, 2nd ed.

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It was only in 1650 that this disease was eventually described in detail in Glisson’s treatise premarin 0.625mg online. Rickets doubtless played a substantial role in past centuries cheap 0.625 mg premarin with mastercard, primarily in northern countries 0.625 mg premarin amex. Nevertheless cheap premarin 0.625 mg without a prescription, while Glisson believed that the curva- ture of the spine was also attributable to this condition, this was likely to be the case in only a few instances. Nicolas Andry: The famous illustration from the book L’Or- thopédie ou L’art de Prévenir et de Corriger dans les Enfants, les Difformités »idiopathic« or neurogenic in origin. The crooked tree splinted by a rope to a straight post cause of these conditions remains unexplained. The only has become the globally recognized symbol of orthopaedics difference is that we can now describe it in more sophisti- 18 Chapter 1 · General cated terms. At all times, however, paralytic scoliosis due ten or graphic portrayals of such treatments. Only the use 1 to poliomyelitis has probably been more prevalent than of crutches has been depicted repeatedly in records from idiopathic scoliosis. But the era of corrective measures vaccination at the start of the 1950’s that this disease was starts with Hippocrates. He described corrective manipu- finally eradicated, first in the industrial nations and nowa- lations similar to those that are still in use today. Only in recent years has there been a de- correcting the position of the foot. A similar situation also applies, Hippocrates was also doubtless familiar with congeni- incidentally, to idiopathic scoliosis. The frequency of tal hip dislocation, even though he was unable to offer a inherited systemic disorders is very closely dependent on corresponding treatment. For curvatures of the spine he the degree of relationship of the parents and is therefore recommended the following treatment: The patient is tied also indirectly influenced by religious, cultural and social to an upright ladder either by the feet or around the chest. This ladder is then repeatedly raised using ropes and al- The idea that incest might be sinful only emerged in the lowed to fall under its own weight. The consequences of marriage between the application of the extension principle, which was relatives were no doubt observed and clear conclusions subsequently described in the book Chirurgia è Graeco in drawn. Thus we read in Deuteronomy 27, verse 22: Latinum conuersa by Guido Guidi (Vidus Vidius, approx. While fractures were The taboo of inbreeding has persisted in the Jewish and treated with this material right from the start, this ap- Christian religion to the present day. This taboo is less strict plication of plaster only reached Europe at the end of the in the Islamic social order and is also less likely to be ob- 18th century. As a result, hereditary The options for conservative treatment were neither diseases are more common in these societies, although such significantly extended nor refined during the Middle illnesses – particularly among primitive peoples – have not Ages. Although the archetype as it were of the brace was become a social problem. Even today in certain tribes, created with the arrival of medieval iron armor, this did children with obvious birth defects are abandoned and left not have any corrective effect, nor was it used as a thera- out to be killed by wild animals. Corrective splints for treating contractures with Little disease or other types of cerebral palsy. These are very reminiscent of a children who were evidently failing to thrive were left to knight’s armor. Ambroise Paré (1510–1590) treated cases of scoliosis palsy attributable to difficult births has declined thanks with braces made from thin plates of perforated iron in to improvements in obstetrics and neonatology. The extension principle with a high risk of complications, the decision to proceed was refined by Francis Glisson (1597–1677) with his to cesarean section is now taken at an early stage. Even today, the Glisson However, the proportion of severe cerebral palsies has sling is still to be found in orthopaedic hospitals. This generally involves tion beds also subsequently came into widespread use. Bone tumors have likewise Then, in the 20th century, came the arrival of plastic, a always been with us, although these were neither correctly lightweight, dimensionally-stable material. Patients with milestone was reached in the 1940’s with the development such conditions tended to be left to their fate.

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The need to wait at least 3 weeks until the second surgery and the separation of the flap from its donor tissue make it very difficult to care for the burned limbs and prevent proper mobilization therapy and splinting order premarin 0.625mg free shipping. For these reasons these flaps are increasingly being replaced by regional fasciosubcutaneous flaps order 0.625mg premarin visa, or free flaps order 0.625mg premarin free shipping, for coverage of complex injuries of the limbs premarin 0.625mg free shipping. Some very useful examples are fascial axial flaps, fasciosubcutaneous flaps, or reverse-flow fasciocutaneous flaps based on the radial, cubital, or posterior interosseous arteries for hand coverage. These flaps also allow the transfer of segments of tendon, muscle, or bone, which adds great versatility to reconstruction methods. The reverse-flow radial flap, as described by Lu in 1982, is a modification of the free antebrachial fasciocutaneous flap described by Yang in 1978. It is a flap based on the septal perforating branches of the vascular system of the radial artery, perfused in a retrograde direction from the palmar arch, whose permeability is tested preoperatively using the Allen test. Venous drainage occurs in a retrograde fashion through the concomitant radial veins, which occasionally creates initial signs of venous congestion that later disappear. It is very important to exercise maximum caution while dissecting the fascial wall to avoid damaging the superficial branches of the radial nerve in the distal third of the forearm. Figure 4 shows an example of the placement of this flap in the treatment of a severe hand burn. The reverse-flow cubital flap, described by Jin in 1985, is very similar to the one just described and is used less frequently since it is considered the main vascular supply to the hand. The feasible cutaneous territory of this flap is less than the flap based on the pedicle of the radial artery. The reverse-flow fasciocutaneous flap based on the posterior interosseous artery was described by Zancolli and Angriniani in 1985. Blood flow arrives in a retrograde fashion to the septocutaneous perforating branches from the posterior interosseous artery via the communicating branch, with the anterior interosseous artery located distally in the forearm. This is indicated specifically for treatment of deep burns of the thumb, the first commissure, and the dorsum of the hand (Fig. In 1988, Ching described the anatomical basis for the antebrachial fascio- subcutaneous flap distally based on septocutaneous perforating branches of the radial and cubital arteries the level of the distal third of the forearm, with the preservation of the integrity of these vascular axes. These flaps are useful for coverage of complex distal injuries of the forearm and hand. The Hand 271 FIGURE 4 Reverse-flow radial flap for treatment of a hand burn. FIGURE 5 Reverse-flow fasciocutaneous flap for coverage of a burned hand. When tissue destruction prevents the use of local or distant flaps and when, necessary for reconstruction, free flaps are indicated for treatment of burned hands. Using microsurgical techniques, it is possible to transfer in a single surgical procedure the tissue necessary for optimal coverage of the exposed blood vessels, nerves, tendons, joints, or bones. This helps reduce the risk of deep infection and necrosis of the exposed soft tissue structures and facilitates early movement of the burned extremity. This is especially relevant for the treatment of patients who have suffered high-voltage electrical burns of the upper limbs. Coverage of the burned hand requires the use of tissues that are not very thick. The existence of this with a fascial component in the flap that allows sliding of the exposed deep structures is another advantage of free flaps. The free radial fasciocutaneous flap, described by Yang in 1981, provides excellent coverage with a thin, pliable tissue with a fascial component on its deep surface. Its vascular pedicle is constant, of large caliber, and has supplementary drainage through the superfi- cial veins of the forearm. This type of flap is contraindicated when the Allen test shows insufficient vascular supply from the cubital system and the posterior interosseous of the hand [26,47] or when the skin of the donor region of the forearm has been burned. We do not reconstruct the radial artery after extracting the flap, and we have not observed any case of poor perfusion of the hand of the donor extremity.

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