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By X. Nefarius. Antioch University Santa Barbara.

The particular problem of uninten- head and socket purchase aricept 10 mg on line, the shape of the cartilaginous socket and tional positional instability of the shoulder in sporting its inclination in relation to the shoulder blade order aricept 10mg on line, as well as adolescents with lax ligaments (see above) can be any torsional defects of the humeral head. The Bankart le- countered by avoiding certain positions and performing sion and the Hill-Sachs groove can also readily be assessed muscle-strengthening exercises. Since MRI scans do not provide much ad- ditional information they are not usually required. Surgical treatment Diagnostic arthroscopy is by far the best method for Possible surgical procedures include the following: identifying capsuloligamentous lesions. However, since it refixation of the Bankart lesion (open or arthroscopi- is an invasive investigation it should be performed only if cally) surgery is already indicated, which is very rarely the case capsular shrinkage (by conventional means or with in children and adolescents. This a bone graft is based partly on the bone configuration and partly on rotational osteotomy of the coracoid (Trillat operation) a constitutional ligament laxity. Since the collagenous rotational osteotomy of the humerus tissue steadily shrinks in individuals with lax ligaments, this phenomenon has a positive influence on the course One deciding factor for treatment is the presence or ab- of the condition. The lesion is present in 80% ments should not be repeatedly overstretched. Voluntary of traumatic dislocations and nowadays tends to be dislocation, in particular, must be avoided. The repair of the Bankart lesion produces good tary shoulder dislocations over an observation period of results in children and adolescents in a high percentage 12 years revealed a good, problem-free status in 16 cases, of cases [7, 14, 15]. The combination of refixation of the while surgery was required in only 2 cases. By contrast, in Bankart lesion with capsuloplasty can produce satisfac- 7 patients with a similar initial situation who underwent tory results even if multidirectional instability is present. Exercises from the San Antonio muscle training program at the shoulder (right). She moves her upper then pulls on the cord by rotating the arm outwardly at the shoulder body closer to the wall by flexing the arm at the elbow (right) and then (right). Definition Most of the other operations are associated with, in Conditions involving disorders of the bones and joints of some cases serious, drawbacks. The overlapping of the the upper extremities that occur in growing children and subscapularis muscle and anterior capsular shrinkage re- adolescents, generally in connection with overexertion. A posterior dislocation can occur after bone grafts or a rotational os- teotomy of the coracoid according to Trillat. Basically, one should attempt to reconstruct resembling that of Legg-Calvé-Perthes disease. The the disrupted anatomy rather than create a new pathology term »Panner’s disease« was then coined by Smith in 1964 by performing procedures outside the actual lesion. This condition affects children under 10 years of age with pain and swelling in the elbow area. Bankart ASB (1923) Recurrent or habitual dislocation of the shoul- areas in the vicinity of the capitellum with central brigh- der. Burkhead WZ, Rockwood CA (1992) Treatment of instability of the The joint cartilage is not affected by the condition. J Bone Joint Surg (Am) 74: pathogenic mechanism is probably similar to that of 890–6 3. An analysis of other forms of aseptic bone necrosis (Legg-Calvé-Perthes family history. Gohlke F, Eulert J (1991) Operative Behandlung der vorderen dissected, the prognosis of the disease is good. Orthopäde 20: 266–72 and temporary splinting are the most useful measures. Huber H, Gerber C (1994) Voluntary subluxation of the shoulder If a fragment threatens to break off (which is very rare in children. J Bone Joint Surg (Br) 76: 118–22 in this age group), it should be refixed (if possible with 6. Kuroda S, Sumiyoshi T, Moriishi J, Maruta K, Ishige N (2001) The a resorbable polylactate screw) or (if this is not possible) natural course of a traumatic shoulder instability. Lawton R, Choudhury S, Mansat P, Cofield R, Stans A (2002) Pedi- atric shoulder instability: presentation, findings, treatment, and outcomes.

Axonotmetic W aveform parameters include amplitude generic aricept 5mg with amex, latency buy 10mg aricept with visa, and injuries involve damage to the axon with preservation conduction velocity. It measures afferent and efferent examined with EDX (Wilbourn and Shields, 1998). Consequently, small focal abnormalities tend to lyzed and this offers an opportunity to distinguish be obscured by the longer segments. This can be particularly helpful in distinguish- The NE evaluates the entire motor unit (lower motor ing an athlete’s acute or chronic nerve injury. They are found when the muscle nerve entrapment as it exits the fascia of the lateral tested has been denervated (Dimitru, 1995). They represent a group of single muscle of piriformis syndrome is more apparent when an H fibers that are time-linked because of crosstalk reflex is performed with sciatic nerve on stretch (hip between neighboring muscle fibers. They represent These techniques need to be interpreted with caution as many abnormal readings occur based on measure- ment error alone. TABLE 19-3 Grading of Fibrillations and Positive Waves GRADING CHARACTERISTICS QUANTITATIVE ELECTROMYOGRAPHY 0 No activity 1+ Persistent (longer than 1 s) in 2 muscle regions 2+ Persistent in 3 or more muscle regions Demonstrates sequence of muscle recruitment and 3+ Persistent in all muscle regions muscle force. CHAPTER 19 ELECTRODIAGNOSTIC TESTING 115 Surface or needle electrodes placed into muscles to a. Properly timed EDX studies can differentiate a record EMG signals through multiple channels. The acuteness and chronicity of the nerve lesion Has been used to assess the degree of muscle fatigue may also be assessed using fibrillation ampli- and biomechanics of sports activities (Feinberg, tude and motor unit analysis, as well as clinical 1999). EDX studies are useful to correlate nerve func- larly at the termination of the swing phase in prepara- tion to anatomic abnormalities. This may be particularly useful in the spine group also work during a greater percentage of the because disc herniations effacing nerve roots swing and stance phase during running than in walk- can be seen in asymptomatic individuals ing. By determining the degree of nerve injury, the Surface EMG can be used as a biofeedback technique clinician can predict nerve function recovery. CMAP amplitude measurements of weak mus- cles (compared with asymptomatic contralateral INDICATIONS FOR EDX TESTING amplitude) can give an idea of the extent of neu- roproxia and of potential recovery. A side-to-side amplitude difference of greater estimated following a thorough history and physical than 50% is probably significant. The best determination of return to play remains Some useful generalizations about the indications for the athlete’s functional performance in simu- EDX studies are the following (Press and Young, lated sports activities (Feinberg, 1999). EDX examination can rule in a suspected diag- LIMITATIONS OF EDX TESTING nosis or rule out a competing diagnosis. EDX studies may alert the possibility of an Electrodiagnostic testing is not a perfect test and unsuspected concomitant pathologic process should not be performed in every athlete with neuro- (i. Nerve injury localization often needs to be logic deficits following a traumatic posterior knee dis- objectively confirmed prior to contemplating location, which should be treated emergently). An athlete presenting with plantar foot numb- should be kept in mind (Table 19-4). EDX studies can be used to determine if the sci- determine the degree of nerve injury. Determine the extent and chronicity of nerve nous fistula, open wound, coagulopathy, lym- injuries. SPECIFIC CONDITIONS Athletes may commonly present with tibial and per- oneal nerve problems which can be evaluated by EDX Many pain complaints in athletes present as neuro- techniques. TIBIAL NERVE Although most long distance runners do not complain of symptoms of neuropathy, they do appear to have sub- There are specific EDX techniques to evaluate the clinical changes in quantitative sensory thresholds and tibial nerve and its terminal branches (Park and Del nerve conduction velocities (Dyck et al, 1987). TABLE 19-5 Focal Entrapment Neuropathies Seen in Runners SYNDROME/NERVE SYMPTOMS ENTRAPMENT SITE Tarsal tunnel syndrome (tibial nerve Plantar pain/paresthesias, worse at night and with Under flexor retinaculum proper) prolonged standing or walking Medial calcaneal neuritis Medial heel pain At medial heel Inferior calcaneal nerve (first branch Chronic heel pain, no numbness, weakness of Between AH and QP or calcaneal heel spur of lateral plantar nerve) ADM Medial plantar nerve (jogger’s foot) Medial arch pain At master knot of Henry (hypertrophy of AH) Morton’s toe (interdigital nerve) N/T in toes At intermetatarsal ligament Superficial peroneal nerve Lateral ankle pain At deep crural fascia as exits lateral Fascial herniation compartment Deep peroneal nerve Dorsum of foot pain At inferior extensor retinaculum Tightly laced shoes Common peroneal nerve N/T in lateral leg, dorsum of foot Compression in fibular tunnel by fibrous edge of peroneus longus Traction from ankle sprains ABBREVIATIONS: N/T = numbness/tingling; AH = abductor hallucis; QP = quadratus plantae; ADM = abductor digiti minimi CHAPTER 19 ELECTRODIAGNOSTIC TESTING 117 The medial plantar nerve is easily tested as a motor Prognosis is critical if obtainable nerve conduction study, stimulating at the tibial nerve Comparison with previous EDX data whenever possible proximal to the medial malleolus and recording over the abductor hallucis. PERONEAL NERVE REFERENCES The peroneal nerve’s motor and sensory components Bachner EJ, Friedman MJ: Injuries to the leg, in Nicholas JA, can be consistently studied with nerve conduction Hershman EB (eds. Baltimore, MD, Williams & ankle, the fibular head, and the popliteal fossa. Mayo Clin Proc The sensory nerve study is performed by stimulating 62:568, 1987.

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Depending on the stage of the illness buy 10mg aricept with amex, so that the nature of the defect can be established 5 mg aricept sale. Treatment involves very high doses of vitamin D ▬ Vitamin D-resistant rickets: The signs and symptoms (between 50,000 and 100,000 IU). Phosphate must are very similar to those of vitamin D-deficiency rick- also be replaced depending on the serum concen- ets, but generally more pronounced and not rectifiable tration in each case. The condition is Orthopaedic treatment: We consider that the once usually diagnosed at around the age of 2 years, but common treatment with splints or cast fixation is not severe forms can manifest themselves after just a few appropriate. The laboratory tests show hypophos- addition to the osteomalacia, thus further promot- phatemia and an elevated alkaline phosphatase level. Children with rickets lack The other electrolytes and the pH are usually within drive and start to walk at a late stage. Moreover, splints are not even capable of but can also occur in connection with Blount disease. A lower leg splint on The possibility of renal osteodystrophy should also be its own can never correct a pronounced genu varum considered in the differential diagnosis. Treatment No specific treatment is required for a patient with ▬ Treatment of the underlying condition: vitamin D-deficiency rickets with genua valga or vara – Vitamin D-deficiency rickets can be prevented or provided the axial deviation is less than 15°. Vitamin corrected by the daily administration of 500 IU of D replacement will correct the osteomalacia in a rela- tively short time, and the axial deviation will normal- ize itself spontaneously. If the axial deviation is greater than 15°, a corrective os- teotomy should be considered, since the displacement of the force resultants limits the possible spontaneous correction. If the pressure on the epiphyseal plates is excessive on one side, they react with bone resorption instead of bone formation. The correction should be made at the site of the deformity, usually in the lower legs, although the thighs may also be bowed. If both the femur and tibia are bowed, then both bones will need to be corrected, ideally at supracondylar level in the femur and at infracondylar level in the tibia, i. In the case of small children, we always perform the osteotomies without wedge removal, preferring to place the bone in the de- ⊡ Fig. AP x-rays of both knees of a 6-year old girl with vitamin-D- sired, straightened position and fix it with two crossed resistant rickets. This is followed by the fitting of a shaped metaphyses long-leg cast for four weeks. After four weeks, the The increased secretion of parathyroid hormone pro- cast and transcutaneously inserted Kirschner wires duces elevated serum calcium levels accompanied are removed. An external fixator can be used for older by decreased serum phosphorus and raised alkaline children. Another effect of the parathyroid new telescopic Gamma nail can be used (⊡ Fig. The holes are filled with fibrous tissue Renal osteodystrophy occurs in chronic renal insufficiency (hence the alternative name of the disease of osteitis and is very rare in children and adolescents. In addition to generalized osteoporosis, ▬ Various factors play a role in the development of the the x-ray shows stippled zones of resorption. The renal insufficiency leads to secondary histological examination these zones are filled with hyperparathyroidism with high serum concentrations fibrous connective tissue, enriched with giant cells, of parathyroid hormone. The increased secretion of inflammatory cells, macrophages and hemosiderin. The In the differential diagnosis it is important not to con- bones of the legs are more affected than those in the fuse the pseudotumors with genuine tumors. The x-ray shows generalized osteoporosis with thinning of the cortices and bony trabeculae. The epiphyseal plates are widened, and epiphyseal separa- tions are common. The conservative treatment usu- ally involves the administration of vitamin D in very high doses (up to 200,000 IU). Orthopaedic treatment: As with rickets, splint treat- ments and cast fixation should be avoided.

Controversy exists over 1) the long-term use of opioids for non-cancer pain discount 10 mg aricept with amex, and patients receiving opioids for long periods must be monitored carefully for signs of addictive and aberrant behavior order 5mg aricept otc, 2) the impact of opioid therapy on emotional depression in patients with chronic pain, and 3) whether opioid therapy causes cognitive impairment in the elderly. Our ability to determine the validity of such assertions and the exact role of opioids in the treat- ment of chronic pain will benefit from further study. Karger AG, Basel Introduction One third of the United States population will experience chronic pain. In fact, chronic pain is the most common cause of long-term disability in the United States and partially or totally disables nearly 50 million people. Among the therapeutic options for treatment of chronic pain, the use of opioids remains a viable choice. Research into opioid pharmacology over the past 20 years has expanded our knowledge of the mechanism of action of opioids. Many studies on patients with cancer pain have provided insight into the clinical pharmacology of opioids. Research findings support the idea that the pharmacokinetic and pharmacodynamic principles of opioids in cancer patients with pain hold true in patients with chronic, nonmalignant pain. While the use of opioids for chronic cancer pain is widely accepted, the efficacy and role of opioids in the management of chronic noncancer pain has been intensely debated. Opponents argue that there is no place for opioids in the treatment of chronic benign pain and opine that narcotics are a major impedi- ment to the successful treatment of chronic pain. This view is largely based on concerns regarding tolerance, physical dependence, addiction, and adverse affective and cognitive side effects. Much of this debate has occurred till recent years in the absence of randomized clinical trials. Although several recent studies have demonstrated that chronic pain, including neuropathic pain states such as postherpetic neuralgia, is responsive to opioids, these studies have followed patients for relatively short periods of 2 months or less. More careful studies of the long-term efficacy of opioids are needed to determine if tolerance to the analgesic effects of opioids limits its usefulness for long-term therapy. Opioid Effectiveness The appropriate use of opioids in the management of chronic pain demands individualization. That is, one opioid does not ‘fit all’ patients with a certain type of pain. In addition, we lack a mechanistic approach that would guide the management of chronic pain states with specific opioids. The goal in the management of a patient’s pain with opioids is to achieve an optimal bal- ance between the drug’s analgesic effects and any associated adverse effects. According to this strategy, the rational use of opioids should focus on achieving maximum analgesic effi- cacy while limiting toxicity. The success of this approach requires gradual titra- tion of the opioid to the point at which a favorable balance between analgesia and side effects is achieved. Finding this acceptable balance between analgesia and side effects requires frequent interactions between the clinician and patient. Several factors can influence opioid responsiveness in managing chronic pain: specifically, patient-centered characteristics, pain-centered characteris- tics, and drug-centered characteristics. Christo/Grabow/Raja 124 Patient-Centered Characteristics Patient-centered characteristics, such as a predisposition to opioid side effects, reduce opioid responsiveness, irrespective of pain syndrome type. This predisposition may derive from higher than normal plasma levels of opi- oid following a single dose (pharmacokinetic) or even from an exaggerated response to modest levels of plasma opioid (pharmacodynamic). Therefore, side effects after a given dose or doses of opioid are difficult to predict but will prevent the patient from achieving a balance between analgesia and adverse effects. Further, concurrent use of other medications with additive side effects will increase the risk of intolerable opioid side effects at doses that are inade- quate for analgesia. If patients are experiencing psychological distress, they may respond less favorably to opioid therapy. Among the cancer population, patients who receive psychological interventions or psychotropic medication achieve better analgesia with the same opioid and dose than do patients receiving no psycho- logical assistance. Similarly, poor opioid responses by addicted individuals may result from affective disturbances such as depression and anxiety.

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