By M. Esiel. Kendall College. 2018.
Let us assume that a patient has a leg length siderable order 200mcg cytotec mastercard, albeit temporary quality 100mcg cytotec, psychological stress cytotec 100 mcg low cost. Since a maximum height We also have experience with bilateral lengthening discount 100mcg cytotec. The difference of 2 cm is acceptable for the knees discount cytotec 200 mcg on line, we rule that lengthening should not exceed 8 cm in each would only lengthen the femur in this case. We primarily lengthen ▬ If substantial differences of over 20 cm are anticipated, both lower legs and only secondarily both upper legs. If then one should consider very carefully whether the attempt has to be discontinued after the first stage of lengthening is appropriate at all. Such patients usu- the attempt, disproportionately long lower legs are much ally suffer from a longitudinal deficiency of the fibula more readily acceptable from the esthetic standpoint than (i. We therefore tend a fibular aplasia and the absence of the lateral rays to discourage patients with dwarfism from undergoing on the foot; chapters 3. Only if they still persist with their patients often have cruciate ligament aplasia, as well request are we prepared to perform this elaborate proce- as major problems in stabilizing the ankle as a result dure. It is important for them to meet other patients who of the absent or dysplastic lateral malleolus. We stick have already undergone the procedure so that they have a to a relatively simple rule: If three or more rays are realistic idea of the impending mental and physical effort present in the foot, the possibility of lengthening can involved. We no longer use the temporary stapling diaphyseal osteotomy, lengthening with external fix- method proposed by Blount since it is not very reliable. De- ator, followed by packing of the distracted segment finitive epiphysiodesis cannot be performed until relatively with cancellous graft and plating (Wagner method). For several years we lengthening by an osteotomy (compactotomy) in the have been using a very simple percutaneous method of epi- diaphyseal or metaphyseal area, callus distraction with physiodesis. Through a stab incision the germinative layer an external fixator (»callotasis«, »Ilizarov method«). We generally externally-controlled lengthening by means of a di- advise against weight-bearing for the first three weeks. If aphyseal osteotomy and the fitting of an intramedul- this is not possible however, full weight-bearing is also lary lengthening apparatus [3, 8, 17]. We have also performed this epiphysiodesis on both sides at the same time (in pa- Callotasis according to Ilizarov’s method has gained the tients with macrosomia) with immediate postoperative full most widespread acceptance in recent years [5, 14, 20]. This method is also suitable for physeal The Wagner method is associated with too many com- closure following a tumor resection on the other side. Here, plications, as has been shown not only by a study in our too, full weight-bearing is required from the outset. The difference between the Wagner method and Shortening osteotomy the Ilizarov method concerns not so much the lengthen- Leg shortening of up to 4 cm for the femur and up to 3 ing apparatus, but rather the fact that a cancellous bone cm for the lower leg is possible. The most reliable type of graft is inserted and stabilized with a plate in the Wagner shortening procedure at femoral level is an intertrochan- method after the appropriate length has been achieved teric osteotomy (⊡ Fig. This is a non-biological tech- sons, shortening only up to 3 cm or so is possible at this nique. A higher figure is only possible if the osteotomy is into weight-bearing bone only very slowly, fractures and performed in the shaft area, but the subsequent healing plate breakages were common. Shortening in excess of 4 Distraction epiphysiolysis has also failed to catch on, cm is not possible because the muscles would be weakened since premature physeal closure often occurs as a result of for a very long time postoperatively. However, the relative overlength of the muscles, the risk of thrombosis premature physeal closure means that the final amount of is also fairly high. This also applies to the lower leg, where lengthening is extremely difficult to predict, since short- the osteotomy is usually performed through the diaphysis, ening then occurs after the lengthening. This involves an osteotomy with the chisel, with preservation of the medullary vessels. Alternatively, a transcutaneous osteotomy can be performed with a drill. Principle of intertrochanteric shortening osteotomywith Z-shaped osteotomy and fixation with 90° angled blade plate. If the bone does not bend the screws can then be removed a few days later. Medullary nails Internal medullary nails represent an attractive alternative as they also allow the length to be controlled externally. With the ISKD nail (Intramedullary Skeletal Kinetic Distractor), the rota- tional movement that occurs during walking is translated into the lengthening of a threaded medullary rod. With the Albizzia nail (named for a fast-growing Mimosa tree), manual rotational movements of 20° must be made in order to produce the lengthening.
A hemangiopericytoma is a low-grade malignant tumor 200 mcg cytotec otc, and complete recovery can generally be achieved with a resection extending into healthy tissue cheap cytotec 100 mcg line. Very rare tumor that is completely unrelated to ameloblastoma of the jaw trusted cytotec 200mcg, which – in former times – also used to be known as an adamantinoma purchase cytotec 100 mcg with amex. Occurrence order cytotec 200 mcg overnight delivery, site Very rare tumor occurring primarily between the ages of 10 and 40. Over 90% of all cases are located in the tibia, mainly in the di- aphysis, and possibly also in the metaphysis. Clinical features Since the tumor grows very slowly it causes few symptoms, although diffuse pain can occasionally occur. AP and lateral x-rays of an adamantinoma of the tibia in a may notice a nodular, bumpy surface on the anterior as- 17-year old female patient 621 4 4. Occasionally, Diagnostic value of the molecular genetic detection of the t(11,22) translocation in Ewing’s tumors. Virchows Arch 425: however, spindle cell epithelial formations occur that 107–12 are almost impossible to differentiate from the stroma 12. Fagioli F, Aglietta M, Tienghi A, Ferrari S, Brach del Prever A, Vas- Cytokeratin-positive individual cells in an osteofibrous sallo E, Palmero A, Biasin E, Bacci G, Picci P, Madon E (2002) High- dose chemotherapy in the treatment of relapsed osteosarcoma: dysplasia-like stroma constitute a special variant (osteo- an Italian sarcoma group study. J Clin Oncol 20: 2150–6 fibrous dysplasia-like adamantinoma) that is rarely able 14. Fellinger EJ, Garin-Chesa P, Glasser DB, Huvos AG, Retting WJ to metastazise. Am J Surg Pathol 16: 746–55 The tumor must be resected widely, otherwise it will re- 15. If left untreated, or usually after several recurrences, Mangham D, Davies A (2002) Risk factors for survival and local it can also metastasize. J Bone Joint Surg Br 84: is very important, therefore, to differentiate it unequivo- 93–9 cally from osteofibrous dysplasia, which is generally not 16. Gedikoglu G, Aksoy M, Ruacan S (2001) Fibrocartilaginous mes- enchymoma of the distal femur: case report and literature review. An intralesional resection Pathol Int 51: 638–42 of the adamantinoma is not sufficient. Grimer R, Taminiau A, Cannon S (2002) Surgical outcomes in os- bridging procedures are required after wide resections teosarcoma. Grimer RJ, Bielack S, Flege S, Cannon SR, Foleras G, Andreeff I, rarely involved, functionally effective bridging is usually Sokolov T, Taminiau A, Dominkus M, San-Julian M, Kollender Y, Gosheger G (2005) Periosteal osteosarcoma–a European review of possible. Guo W, Wang X, Feng C (1996) P53 gene abnormalities in osteosar- References coma. Hefti FL, Gächter A, Remagen W, Nidecker A (1992) Recur- Bertoni F, Versari M, Pignotti E (2002) Osteosarcoma of the limb. Bacci G, Ferrari S, Longhi A, Donati D, Manfrini M, Giacomini S, Bric- 21. Hefti F, Jundt G (1995) Is the age of osteosarcoma patients increas- coli A, Forni C, Galletti S (2003) Nonmetastatic osteosarcoma of ing? J Bone Joint Surg (Br) 77: (Suppl II) 207–8 the extremity with pathologic fracture at presentation: local and 22. Hoogendorn PWC, Hashimoto H (2002) Adamantinoma in: Tu- systemic control by amputation or limb salvage after preoperative mours of the soft tissues and bone. Itala A, Leerapun T, Inwards C, Collins M, Scully SP (2005) An Ayala AG (1990) Extraskeletal osteosarcoma. Jürgens HF (1994) Ewing’s sarcoma and peripheral primitive neu- K, Kotz R, Salzer-Kuntschik M, Werner M, Winkelmann W, Zoubek roectodermal tumor. Curr Opin Oncol 6: 391–6 A, Jürgens H, Winkler K (2002) Prognostic factors in high-grade 25. Jundt G, Remberger K, Roessner A, Schulz A, Bohndorf K (1995) osteosarcoma of the extremities or trunk: an analysis of 1,702 Adamantinoma of long bones-A histopathological and immuno- patients treated on neoadjuvant cooperative osteosarcoma study histochemical study of 23 cases. Burchill S (2003) Ewing’s sarcoma: diagnostic, prognostic, and B, Branscheid D, Kotz R, Salzer-Kuntschik M, Winkelmann W, Jundt therapeutic implications of molecular abnormalities.
If the femoral neck angle is greater than normal proven cytotec 100mcg, and the lever arm of the abductors correspondingly shorter buy 100 mcg cytotec visa, the force resultant increases cheap cytotec 100 mcg overnight delivery. The reverse situation ap- plies with coxa vara generic cytotec 100mcg amex, in which the femoral neck angle is smaller discount 200mcg cytotec, thus lengthening the lever arm of the abductors (⊡ Fig. However, Pauwels’ calculations are based on a two- dimensional model and can only provide rough ap- proximations. By no means should one conclude that an increased femoral neck-shaft angle necessarily results in overloading of the hip. Firstly, the valgus position of the proximal end of the femur does not exist in reality, but only produces a coxa valga in projection if the antever- ⊡ Fig. The compression and tension trajectories at the proximal sion angle is elevated. Secondly, the loading of the hip end of the femur can be seen on any AP x-ray of the hip cannot be determined from just one single parameter since a wide variety of factors are involved. The varus osteotomy that often used to be implemented on the basis of theoretical considerations resulted in the recur- Anteversion of the acetabulum plays an important rence of a valgus position during subsequent growth, as biomechanical role. It refers to the angle formed by the this was required by the anatomical circumstances in a acetabular opening and the horizontal plane. If the anterior and poste- compression, and that the force resultant is approx. This stimulates craniolateral and the posterior rim of the acetabulum is medial to the growth and therefore also influences the development of center of the femoral head in a well-centered hip (»poste- the neck-shaft angle. Loading – three-dimensional analysis Apart from the shape of the femoral head, its posi- A three-dimensional view of the anatomical situation is tion in relation to the femoral neck crucially affects the needed to calculate the loading of the hip joint. The head must loaded area is known can the pressure distribution and be centered over the neck so that it projects beyond the loading be determined, and this is usually possible only neck anteriorly. This is know as the offset of the head [9, with complex mathematical calculations [3, 8, 13, 15, 22, 19, 21]. The author has developed a relatively simple method for determining the contact area between the acetabulum Calculation of loading and femoral head, subject to the requirement that the In a double-leg stance, only external forces act on the hip femoral head and acetabulum are roughly spherical and via the weight of the body. The pelvis rests on both femo- that the bony parts of the hip are largely fully developed. No muscle forces are required in the frontal The method can be applied to girls from a skeletal age plane. The situation is different for a single-leg stance of 10 years and, correspondingly, to boys from 12 years or during the stance phase while walking. The various sizes of the template are shown counting the rectangles and triangles located under the in ⊡ Fig. This pattern can be copied onto a sheet of anterior or posterior rim of the acetabulum, the percent- transparent film. The sheet with the template of the ap- 3 age of the covered area in relation to the total surface propriate size is placed over the hip x-ray (⊡ Fig. Finally, the value The percentage and area can be determined very simply ⊡ Fig. Schematic view of the forces in the hip according to Pauwels a in the normal hip, b valgus hip and c varus hip. The diagram shows the effect produced by a change in the lever arms on the acting forces (G Center of gravity, W Body weight, R Force resultant in the hip, M Forces of the abductors) a b c ⊡ Fig. The percentage in relation to the total surface area of femoral head and the anterior and posterior acetabular rims can also the sphere (lower figure) can be calculated by counting the segments be entered on the templates (also Fig. A method based on the same principle but employing more sophis- ticated computer calculation was recently described. The figures marked on the template also allow an estimate to be made of the angles between the center of the femo- ral head and the anterior and posterior acetabular rims. The two angles for the anterior and posterior sides are read off the template and then marked on the x-ray. The acetabular orientation in both the sagittal and anatomical planes can be determined by drawing a line between the two marks entered for the angles on the ventral and dorsal sides. The template can also be used to calculate the relevant loading of the hip.
She will experience more pain and express more anguish than the first because a secondary factor amplifies the affective dimension of her pain purchase 200mcg cytotec with mastercard. This illus- trates a basic psychological principle: Emotion and cognition are interde- pendent determinants of behavior and subjective well-being purchase cytotec 100 mcg with mastercard. THE LIMBIC BRAIN AND MECHANISMS OF EMOTION The limbic brain represents an anatomical common denominator across mammalian species (MacLean buy discount cytotec 200mcg line, 1990) cheap 200mcg cytotec overnight delivery, and emotion is a common feature of mammals buy discount cytotec 100 mcg. Consequently, investigators can learn much about human emo- tion by studying mammalian laboratory animals. The limbic brain is very complex, and it is the central mechanism of emotion. Early investigators focused on the role of olfaction in limbic function, and this led them to link the limbic brain to emotion. PAIN PERCEPTION AND EXPERIENCE 65 what controversial term “limbic system” and characterized its functions (MacLean, 1952). He identified three main subdivisions of the limbic brain: amygdala, septum and thalamocingulate (MacLean, 1990) that represent sources of afferents to parts of limbic cortex (see Fig. MacLean postu- lated that the limbic brain responds to two basic types of input: interocep- tive and exteroceptive. These refer to sensory information from internal and external environments, respectively. Because nociception by definition involves signals of tissue trauma, it excites the limbic brain via intero- ceptive signaling. Pain research has yet to address the links between nociception and limbic processing definitively. However, anecdotal medical evidence impli- cates limbic structures in the distress that characterizes the experience of pain. Radical frontal lobotomies, once performed on patients for psycho- surgical purposes, typically interrupted pathways projecting from hypo- thalamus to cingulate cortex and putatively relieved the suffering of intrac- table pain without destroying sensory awareness (Fulton, 1951). Such neurosurgical records help clarify recent positron emission tomographic observations of human subjects undergoing painful cutaneous heat stimula- tion: Noxious stimulation activates contralateral cingulate cortex and sev- FIG. The amygdalal and septal divisions are phylogenetically older than the thalamo- cingulate division. The amygdalar division contributes to self-preservation (feeding, attack, defense). The septal division is concerned with sexual behav- ior and procreation. The thalamocingulate division contributes to sexual and family-related behaviors, including nurturance, autonomic arousal, and proba- bly some cognitive processes such as attention. Later, I describe progress in functional brain imag- ing research on pain that further elucidates the relationship of limbic activity to pain. The Autonomic Nervous System and Emotion The autonomic nervous system (ANS) plays an important role in regulating the constancy of the internal environment, and it does so in a feedback- regulated manner under the direction of the hypothalamus, the solitary nu- cleus, the amygdala, and other central nervous system structures (LeDoux, 1986, 1996). In general, it regulates activities that are not normally under voluntary control. Stimulation of the hypothalamus elicits highly integrated patterns of response that involve the limbic system and other structures (Morgane, 1981). Many researchers hold that the ANS comprises three divisions, the sym- pathetic, the parasympathetic, and the enteric (Burnstock & Hoyle, 1992; Dodd & Role, 1991). Broadly, the sympathetic nervous system makes possible the arousal needed for fight and flight reactions, whereas the parasympathetic system governs basal heart rate, metabolism, and respiration. The enteric nervous system innervates the viscera via a complex network of interconnected plexuses. The sympathetic and parasympathetic systems are largely mutual physi- ological antagonists—if one system inhibits a function, the other typically augments it. There are, however, important exceptions to this rule that demonstrate complementary or integratory relationships. The mechanism most heavily involved in the affective response to tissue trauma is the sym- pathetic nervous system. During emergency or injury to the body, the hypothalamus uses the sym- pathetic nervous system to increase cardiac output, respiration rate, and blood glucose. It also regulates body temperature, causes piloerection, al- ters muscle tone, provides compensatory responses to hemorrhage, and di- lates pupils. These responses are part of a coordinated, well-orchestrated response pattern called the defense response (Cannon, 1929; Sokolov, 1963, 1990). It resembles the better known orienting response in some respects, but it can only occur following a strong stimulus that is noxious or frankly painful.
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