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The lesions are believed to spontaneously resolve with skeletal maturation buy generic rumalaya forte 30pills online. The role of the primary care physician is for appropriate identification and consultation and /or referral generic rumalaya forte 30pills fast delivery. Osteoid osteoma Osteoid osteoma is a benign reactive lesion of bone characterized by a central active nidus that is composed of a very highly vascular connective tissue centrum and surrounded by dense reactive bone. Although it has been traditionally taught that the lesions are non-neoplastic, non-inflammatory, or infectious, the behavior strongly mimics that of a localized inflammatory process. The lesion (a) (b) 143 Osteoid osteoma (a) clinically behaves like a low-grade localized infection of bone, which does not result in an abscess, or the more serious sequelae of other types of infection. It is likely that the true etiology will be debated for many years, but the condition is generally self-limiting, occurs more commonly in males, and most commonly affects a single bone. The clinical findings are usually characteristic, although may also be subtle in nature. Pain is the most significant complaint, and very commonly occurs in the evening or at night, awakening the patient from sleep. If the lesion is sufficiently superficial in location, localized tenderness may be present, and there may even be some local deformation from the reactive bone in the region of the lesion. An antalgic gait (painful limp) may be present in lower extremity involvement. Commonly the radiographic appearance is quite typical and consists of a central (b) radiolucent nidus up to 1 cm in size surrounded by dense sclerotic bone adjacent to the nidus (Figures 6. The bony reaction can be quite substantial and usually far more extensive than the central nidus. Standard tomograms and particularly thin cut computed tomography (2–3 mm) images are quite helpful (Figure 6. Bone imaging is an important adjunct and very helpful in defining the exact location. It is common for the disease to run its course within a five-year period whether treated or untreated. Salicylates and other anti-inflammatories have been found to be quite effective in ameliorating the symptoms, although it may take upwards of two to three years of treatment time. Continuing discomfort has often necessitated localized en bloc excision of the lesion, and recently developed computerized tomographic directed needle biopsy has been quite successful without necessitating removal of excessive amounts of bony tissue. Anteroposterior (a) and lateral (b) radiographs of the tibia and chemotherapy have not been found showing fusiform expansion and cortical thickening associated with osteoid to be of value. Histiocytosis X Histiocytosis X is a syndrome best characterized by the presence of granulomatous lesions composed of histiocytes that represent a spectrum of conditions. The term includes Letterer–Siwe disease, Hand–Schuller–Christian disease, and eosinophilic granuloma of bone. Letterer–Siwe disease is the acute disseminated progressive life-threatening form of this histiocytosis, with both visceral and bony involvement. Hand–Schuller–Christian disease is the more chronic disseminated form of histiocytosis X, with minimal or moderate visceral involvement, and bone involvement. The diagnosis and management of these two conditions will be left for more appropriate medical textbooks. Computed tomography image showing a large cortical nidus of bone is a histiocytic granuloma that affects osteoid osteoma. The most common location for involvement is the skull, with the next most common site being the femur. The most common presenting symptom is localized pain in the area of bone involvement. The expansile nature of the lesion may weaken the surrounding bone and lead to fracture. Characteristically the radiographic appearance is that of a radiolucent “punched out” appearance with very little, if any, bony reaction to the lesion unless a fracture is present. A skeletal survey is recommended in nearly all cases to evaluate a more systemic distribution.

Stress fractures can occur at the base of against cortisone injections as these can lead to avascular the 5th metatarsal buy 30 pills rumalaya forte with mastercard, particularly if the foot is in an abnor- necrosis of the Achilles tendon rumalaya forte 30pills cheap. The x-ray shows thick- Haglund’s deformity is a spur-like projection of the ening of the cortical bone and possibly central osteolysis bone over the attachment of the Achilles tendon. The fracture itself is not always visible and, if so, extremely rare in adolescents. A more common condi- rarely as a typical as a fracture gap, but rather as a more tion is posterolateral exostosis, in which the bone projects or less diffuse osteolysis resulting from repair processes. A laterally over the calcaneus slightly in front of the Achilles bone scan shows strong uptake. Rather than a genuine exostosis, this The most important differential diagnosis is an os- is more of an anatomical variant, although it can lead teoid osteoma ( Chapter 3. Widening volves cortical thickening and increased uptake on the the footwear is much more useful than surgical chisel- bone scan. Moreover, the osteolysis of the stress fracture ing, since the subsequent scar is more irritating than the can easily be misinterpreted as a nidus of an osteoid former »exostosis«. The most important distinguishing feature is part of the heel, then an insertion tendinosis of the plantar the fact that the pain in a stress fracture is load-related, 428 3. Brunner best way to achieve this is by fitting a below-knee cast, which immobilizes the fracture and effectively stops the The foot represents the lever arm over which the triceps patient from practicing sport. This biome- 3 after 4 weeks, by which time the fatigue fracture has chanical system is primarily responsible for controlling usually healed. In a patient with foot pain one should always think extend (»plantar flexion – knee extension couple«). Tumors are described preconditions for the efficacy of this process: in chapter 3. Bachmann G, Jurgensen I, Rominger M, Rau W (1999) Die Bedeu- (spasticity). Rofo Fortschr Geb Röntgenstr Neuen Bildgeb Verfahr 171: 372–9 Functional or structural foot deformities are very com- 2. Bohndorf K, Imhof H, Schibany N (2001) Bildgebende Diagnostik mon in neurogenic disorders, and can produce widely akuter und chronischer osteochondraler Lasionen am Talus. It is particularly important to thopäde 30: 12–9 distinguish between functionally relevant and cosmetic 3. Borges J, Guille J, Bowen J (1995) Kohler‘s bone disease of the tarsal navicular. Chao K, Lee C, Lin L (1999) Surgery for symptomatic Freiberg‘s also be differentiated from functionally useful ones so that disease: extraarticular dorsal closing-wedge osteotomy in 13 pa- the treatment can be matched to the individual patient’s tients followed for 2–4 years. A tional improvement is required for standing or walking, typical injury. Groß A, Agnidis Z, Hutchison C (2001) Osteochondral defects of or whether the patient is prepared to wear braces such as the talus treated with fresh osteochondral allograft transplanta- inserts or orthoses. Foot Ankle Int 22: 385–91 A common component in neurogenic foot deformi- 7. Hangody L, Kish G, Modis L, Szerb I, Gaspar L, Dioszegi Z, Kendik ties is a functional or structural equinus foot. In a barefoot Z (2001) Mosaicplasty for the treatment of osteochondritis dis- child with an equinus deformity, the weight-bearing area is secans of the talus: two to seven year results in 36 patients. Foot Ankle Int 22: p552–8 small, which makes it more difficult to maintain an upright 8. Higuera J, Laguna R, Peral M, Aranda E, Soleto J (1998) Osteochon- posture. In most cases, stabilizing aids such as inserts or or- dritis dissecans of the talus during childhood and adolescence. J thoses are required in any case to control other components Pediatr Orthop 18: 328–32 of the foot deformities. Ippolito E, Ricciardi Pollini PT, Falez F (1984) Kohler‘s disease of the through corresponding bedding, help improve dynamic tarsal navicular: long-term follow-up of 12 cases.

There are also a number of studies that demonstrate that mild pain symptoms do not affect self-rated percep- tions of health in older adults purchase rumalaya forte 30 pills with mastercard, but do so in the young (Ebrahim buy rumalaya forte 30 pills on-line, Brittis, & Wu, 1991; Mangione et al. On the basis of these findings, it is clear that older adults underreport pain as a symptom of illness. Seniors are very aware of the increasing prevalence of disease with advancing age, and this is thought to contribute to the widespread misattribution of pain symp- toms. However, attributing mild aches and pains to the normal aging proc- ess greatly reduces the importance of this symptom and alters the funda- mental meaning of pain itself. Other types of pain beliefs and attitudes have also started to attract in- creasing attention from the pain research community. Gagliese and Mel- zack (1997b) reported a lack of age differences in both pain-free individuals and chronic pain patients when using the pain beliefs questionnaire (Wil- liams & Thorn, 1989). This instrument monitors beliefs about psychological influences over pain (i. Re- gardless of age, patients with chronic pain were more likely to endorse psy- 132 GIBSON AND CHAMBERS chological beliefs than organic causes of pain. In contrast, others have noted that chronic pain patients show significant age differences in most of the beliefs as assessed by the cognitive risks profile (Cook, DeGood, & Chastain, 1999). Older adults (60–90) were found to have a lower cognitive risk of helplessness, self-blame, and absence of emotional support, but an increased desire for a medical treatment breakthrough and a greater denial of pain-related mood disturbance. In a recent study, the locus of control scale was used to examine cognitive factors and the experience of pain and suffering in older adults (Gibson & Helme, 2000). Chronic pain patients aged over 80 years were shown to have a greater belief in pain severity being controlled by factors of chance or fate (Gibson & Helme, 2000). This con- trasts with younger pain patients, who endorse their own behaviors and ac- tions as a strongest determinant of pain severity. In agreement with previ- ous studies (see Melding, 1995, for review), a belief in chance factors was also shown to be associated with increased pain, depression, functional im- pact, and choice of maladaptive coping strategies. Finally, using a newly de- veloped psychometric measure of pain attitudes, Yong, Gibson, Horne, and Helme (2001) found that older persons living in the community exhibited a greater belief in the need for stoic reticence and an increased cautious re- luctance and self-doubt when making a report of pain. These findings are in agreement with early psychophysical studies that show that older persons adopt a more stringent response criterion for the threshold report of pain and are less willing to label a sensation as painful (Clark & Mehl, 1971; Harkins & Chapman, 1976, 1977). The finding is also consistent with other recent studies of stoic attitudes in older pain patients (Klinger & Spaulding, 1998; Machin & Williams, 1998; Morley, Doyle, & Beese, 2000) and provides strong empirical support for the widely held view that older cohorts are generally more stoic in response to pain. Another potentially important psychological influence relates to possi- ble age differences in self-efficacy and the use of pain coping strategies. Self- efficacy in being able to use coping strategies to effectively reduce the se- verity of pain does not appear to change between early adulthood and older age (Corran et al. These findings would seem to challenge the commonly held view that older persons have less self-efficacy and instead show a stability and resilience in beliefs of personal competence across the major portion of the adult life span. Studies by Keefe and colleagues (1990, 1991) showed no age differences in the fre- quency of coping strategy use, although there was a strong trend for older adults to use more praying and hoping than their younger counterparts. PAIN OVER THE LIFE SPAN 133 Conversely, older people with chronic pain have been found to report fewer cognitive coping strategies and an increased use of physical methods of pain control when compared to young adults (Sorkin et al. Consistent with others (Gardner, Garland, Workman, & Mendelson, 2001; Mosley et al. Such differences are thought to be more likely due to sociocultural cohort effects rather than to some maturational change per se (Corran et al. The use of catastrophizing as a cognitive cop- ing strategy was found to be the strongest predictor of negative clinical presentation in both young and older adults (accounting for 20–30% of the variation in outcome scores). This finding is consistent with many earlier studies in young adult chronic pain patients (see Jensen, Turner, Romano, & Karoly, 1991, for review) and has since been confirmed in older popula- tions as well (Bishop, Ferraro, & Borowiak, 2001). It is in the use of other coping strategies, however, that age differences start to emerge. In the elderly cohort, self-coping statements and diverting attention were shown to be significant predictors of clinical outcome measures, whereas ignoring pain and reinterpretation of pain sensations were of more importance in young chronic pain patients. As these coping strategies were secondary to catastrophizing and only account for between 5 and 10% of the variation in reports of pain, mood disturbance, and disability, the observed age differ- ence probably represents a subtle shift in the interaction between coping and clinical presentation rather than some major change. In summary, these findings document some clear age-related differ- ences in many types of pain beliefs, coping mechanisms, attribution of pain symptoms, and attitudes towards pain. These psychological influ- ences are likely to shape the overall pain experience, but observed age differences may be very dependent on the intensity of painful symptoms. If a pain symptom is mild or transient in older adults, it is likely to be at- tributed to the normal aging process, be more readily accepted, and be ac- companied by a different choice of strategy to cope with pain.

Surgical treatment The very rarely affected distal ulnar growth plate ▬ Closed reduction under anesthesia and Kirschner wire reacts much more sensitively generic rumalaya forte 30pills without a prescription. In a case of pro- In children over 10 years of age order rumalaya forte 30pills line, completely displaced gressive deformation or shortening, and depending fractures, or fractures that are not adequately reduced in each case on the patient’s age, residual growth and by cast wedging, are reduced under anesthesia and the size of the closure, a bridge resection with fat stabilized by percutaneous Kirschner wire fixation in interposition (Langenskiöld operation), a corrective order to be certain of avoiding the need for second- osteotomy, a lengthening or shortening procedure, ary manipulations (⊡ Fig. The wires are an epiphysiodesis or a combination of these methods bent 90° approx. Elevated circular cut-outs in the cast avoid any direct Pseudarthroses are the rule with avulsions of the sty- contact between the wires and the cast and thus pre- loid process, but are almost never symptomatic. Acute carpal tunnel syndrome and compartment syn- ▬ Plate fixation: dromes of the forearm can occur in the event of the Since angulated and displaced fractures at the me- delayed management of epiphysiolyses or epiphysio- taphyseal-diaphyseal junction in adolescents cannot lyses that are severely displaced in a dorsal direction. The immobi- lization period is four weeks for all fractures, with the exception of plated patients requiring early functional 3. The scaphoid is by far the most Fractures with growth plate involvement should be fol- frequently affected bone, but occurs almost exclusively in lowed up every six months for up to two years after the adolescents. Diagnosis Complications Clinical features ▬ Posttraumatic deformities are conspicuous, particularly The pain in the »anatomic snuffbox« is a helpful indi- in cases of volar angulation. The volar radial tuberosity left to correct themselves spontaneously in younger should also be palpated since fractures frequently affect children, the parents must be told that remodeling will the distal pole. If a scaphoid fracture is suspected, the standard are only mentioned in isolated cases in the literature AP and lateral projections should be supplement- and are usually the result of overlooked fractures ed by oblique views in supination and pronation- or excessively short immobilization periods. The latter are particularly valu- a lengthier period of immobilization will usually pro- able for the detection of fractures at the proximal duce consolidation. The high cartilaginous proportion that persists for hand fractures represent the second commonest group a long time ensures a high degree of elasticity up to ado- after distal forearm fractures. The accident mechanism lescence, which explains the low incidence of fractures in reflects the age-specific activity: small children typically children under 10 years of age. Spe- with adults, the distal third, often outside the joint on cial attention must be paid to hand injuries in neonates the volar side, is the most commonly affected and these or small children as these are a possible indicator of child fractures correspond to bony ligament avulsions. Since fractures of the middle third involve a higher degree of force, the doctor should accordingly look for concomi- Diagnosis tant injuries to the carpus, metacarpus and distal radius Clinical features and ulna. Since this is the last part of the bone to ossify, such tions in the frontal plane and to rotational defects fractures probably remain undiagnosed not infrequently. Rotation is tested at 90° flexion in Fractures of the capitate, triquetrum, hamate, pisiform the metacarpophalangeal joints and the proximal and lunate bones are rare. During normal rotation the after 4 to 6 weeks of immobilization in a cast. Treatment Scaphoid fractures Imaging investigations After initial immobilization in a long-arm cast that Dorsopalmar and oblique x-rays of the hand. In contrast includes the thumb metacarpophalangeal joint, the situ- with the long bones, all the metacarpals and phalanges ation is reassessed clinically after 7–10 days. If the possess only one epiphyseal plate which, with the excep- findings are normal, treatment is considered to be con- tion of the 2nd–5th metacarpals, are always at the proxi- cluded. A so-called pseudoepiphysis on the 1st distal immobilization is continued for another two weeks even metacarpal and, less frequently, the proximal 2nd–5th if the x-ray findings appear normal. The same also normal radiological results still persist after these two applies to a congenital radial deviation of the little finger, weeks, an MRI scan of the wrist is indicated with the also known as Kirner’s deformity. A total immobilization Fracture types period of 6–8 weeks is sufficient, except for initially The digits at either end of the hand, i. Phalangeal frac- weeks, the long-arm cast can be replaced with a forearm tures are more common than metacarpal fractures and cast. The nature and site of the fractures Once consolidation and free function have been achieved, show a clearly age-related pattern, with predominantly the treatment can be considered as concluded. The need for a correct functional ▬ Metaphyseal compression fractures are often not visible position, with 70–90° flexion in the metacarpophalangeal on the x-ray and are therefore often missed. Closed reduction ▬ Subcapital metacarpal fractures occur as a result of Extra-articular fractures with axial deformities in the punching, usually by male adolescents, against a hard frontal plane (ulnar or radial deviations) or rotational object (boxer’s fracture) with a flexion deformity of defects require a closed reduction and, if instability is the head of the 5th metacarpal or, more rarely, the 4th present, fixation. Only epiphyseal separations on the intermetacarpal ligaments, severe shortening or dis- phalanges can be treated simply be reduction and cast placements rarely occur.