By R. Tyler. Abilene Christian University.
This problem Nes avanafil 50mg without a prescription, hence the more usual term in the English-speak- does not exist if allogeneic bone grafts (allografts) are ing literature of »Van Nes rotationplasty« purchase avanafil 50mg otc. The rotation- used since the healthy part of the joint does not need to plasty is a special form of amputation in which the upper be replaced. It was originally used for osteosarcomas of the distal femur Concurrent closure of the epiphyseal plate as a way of improving function after tumor resections. At a Even though the rotationplasty is not a limb-preserv- bone age of 10 years, the distal femur is expected to grow ing method it does provide much better function com- a further 6. Gait analyses have shown while the anticipated further growth in the proximal tibia that children with rotationplasties can walk much faster under the same conditions is 4. The result is func- osteosarcomas tend to be fairly tall, this method can tionally equivalent to a lower leg amputation and can also often be used in adolescents. The patient is spared from be achieved by this method for tumors of the upper leg. Types of rotationplasty according to Winkelmann: Type BII for additional involvement of the muscles near the pelvis, Type AI for a tumor on the distal femur, Type AII and Type AI for a tumor Type BIII for a tumor affecting the whole femur on the proximal lower leg, Type BI for a tumor on the proximal femur, 642 4. Example of a rotationplasty in a 9-year old boy with an osteosarcoma on the distal femur. Since experience has been gained with section incorporating an electric motor in the manner of hundreds of rotationplasties worldwide, this operation the Fitbone medullary nail. Initial results are encouraging has established itself as a standard method for tumors although no firm recommendations can be provided at close to the growth plate in children under 10 years of age this stage. The chances of participating in athletic activites for several decades of life are better by far with a Conventional approach with leg lengthening rotation plasty than with a tumor prosthesis. The main problem is the need for an Another option for bridging after resections during external fixator for the lengthening process. Since this is growth is the use of extendable prostheses [2, 11, 13, 14] anchored in the bone transcutaneously infections repeat- that have been developed in certain centers. Large prostheses or allogeneic bone grafts are the drawbacks of a bulky prosthesis for a growing child, already at risk of infection, and the extension involves a all are associated with the additional problem of the need not insubstantial risk of secondary infection. Furthermore, since the shaft of a long Treatment of bone and soft tissue tumors bone grows not only in length but also in diameter the – a multidisciplinary task anchorage can loosen simply as a result of growth. Recent The objective of our efforts is to preserve the physical, investigations, however, have shown a high complication and thus also the mental, integrity of the patient. Many rate, but a loosening frequency comparable with adult specialists are involved in the decision concerning the prostheses [2, 11, 14]. A recent innovation is the MU- appropriate treatment and its implementation. Since ma- TARS prosthesis with an externally controlled extendable lignant bone tumors are rare the necessary experience 643 4 4. But in return team includes, in addition to the orthopaedic surgeon, an we can offer – at least in respect of bone tumors – a con- oncologist, radiologist and bone pathologist. All of these siderable improvement in life expectancy and quality of specialists should – if not exclusively at least primarily life, and this at an age when no-one can ask whether this – be working in the field of bone tumors. A particularly useful diagnostic resource at our related (particularly if it occurs at night), an x-ray disposal is the bone tumor register, which was set up in should always be arranged. If a bone tumor is sus- 1972 by the Basel Institute for Pathology and currently pected, the patient should be referred, if possible includes over 11,000 bone tumors and tumor-like lesions. This particu- larly applies to bone tumors, since they are not only rare, but also subject to substantial variability in terms of their References appearance and prognosis.
No further mention need be made of type II (lethal ▬ Differential diagnosis: Osteogenesis imperfecta can be form) trusted avanafil 100mg. In the other types generic 50mg avanafil overnight delivery, the ability to walk is of crucial confused with camptomelic dwarfism, in which bow- significance for the patient’s quality of life (and probably ing of the long bones also occurs. A study in the UK showed that ingly occur also in cystinosis and pyknodysostosis. It those children who are able to sit up freely by the age of is important to rule out child abuse, in which mul- 10 months will very probably be capable of walking and that tiple fractures are often observed at the same time. In the long term, the telescopic nails cause No known treatment currently exists for the underly- additional iatrogenic joint damage, above and beyond ing condition. A form of gene therapy aimed at replac- the damage that is already produced by the disease, ing the missing enzyme, at least for type I, is currently particularly in the ankle joint. Encouraging results have recently The nails must be custom made for each patient, and been obtained with treatment designed to improve bone the size and thickness of the nails must fit precisely. The orthopaedic treatment must address two main Inserting the nails through bone that is often bowed is problems: the fractures and bowing of the long bones and difficult. The bowing tendency of the bone ▬ The fractures, which occur mainly during childhood places eccentric loads on the nails. Pushed together, represent a huge problem for the affected patients and the two components of the nail can become wedged, their whole environment. Not infrequently the inserted from the knee and which can be locked in the children lost the ability to walk as a result of this sec- distal epiphysis (⊡ Fig. For the femur we ondary osteoporosis, even though they might enjoy have developed a telescopic Gamma nail, which can largely normal bone strength on completion of growth be inserted from the greater trochanter and is locked thanks to the osteogenesis imperfecta. It allows correc- Classical fracture management for children involved tion of the varus deformity, which is always present in conservative treatment with cast fixation or surgical the bowed femur (⊡ Fig. Alternatively, two flexible intramedullary nails can be These two operations are totally unsuitable in osteo- used. These nails are more readily available since they genesis imperfecta since, in addition to the existing can also be used for the management of conventional bone brittleness they introduce further predetermined fractures. Because of their rigidity and the phe- through the epiphysis into the bone. In the femur one nomenon of stress shielding they further reduce bone nail is inserted in each case from the proximal and strength, and repeated fractures usually occur during distal ends. The problem that usually arose was The joints remain unaffected in this procedure. The that the nails became too short with growth, resulting flexible intramedullary nails are much easier to intro- in new fracture sites at the nail end. A breakthrough duce than telescopic nails and custom manufacture is emerged with telescopic nails, which were introduced not required. These are two-part nails in which a during the insertion of the flexible intramedullary pin slides inside a tube. The nails are inserted into both nails since the bone is very brittle and can easily per- epiphyses and advanced through the epiphyseal plate forate. The pin is then introduced into even though no infection is present. As the Spinal deformities: Scolioses, in some cases severe forms bone grows the two parts gradually slide apart, thus often with a pronounced kyphotic component, occur ensuring that the whole bone remains splinted, until in around half of the patients with type I osteogenesis the bone has doubled in length. The treatment of these scolioses is difficult of its operating principle, this system has obvious ad- since corset treatment is ineffective.
Inferior glenohumeral ligament – The primary anterior ligament stabilizer above 90˚ FIGURE 4–9 avanafil 50mg visa. The glenohumeral ligaments (anterior view) depict a distinct Z pattern formed by the superior glenohumeral ligament buy cheap avanafil 100 mg on-line, the middle glenohumeral ligament, and the inferior glenohumeral ligament. Long head of the biceps tendon, deltoid, and teres major Static Stabilizers Include the articular anatomy, capsule, ligaments, as well as the glenoid labrum MUSCULOSKELETAL MEDICINE 137 MEDIAL ROTATORS Pectoralis major Anterior deltoid Subscapularis Latissimus dorsi Teres major LATERAL ROTATORS Teres minor Posterior deltoid Infraspinatus FIGURE 4–10. This diagram depicts the relation of the rotators to the upper end of the humerus. Right glenoid cavity of the scapula as viewed from the anteriolateral aspect. Note four short rotator cuff muscles (teres minor, infraspinatus, supraspinatus, and subscapularis). Note the contribution of the coraco-acromial ligaments to the inferior acromio-clavicular joint capsule. Acromioclavicular (AC) ligament Connects the distal end of the clavicle to the acromion, providing horizontal stability 2. Coraco-clavicular (CC) ligament This ligament is made up of 2 bands: Conoid and trapezoid Connects the coracoid process to the clavicle, providing vertical stability 3. Coraco-acromial ligament Connects the coracoid process to the acromion Mechanism of Injury A direct impact to the shoulder Falling on an outstretched arm MUSCULOSKELETAL MEDICINE 139 Classification of AC Joint Separations (See Figure 4–13) TABLE 4–1 Ligament Acromioclavicular Coracoclavicular Clavicular Displacement Type I Partial sprain Intact None Type II Complete tear Partial sprain None Type III Complete tear Complete tear Superior Type IV Complete tear Complete tear Posterior and superior into the trapezius, giving a buttonhole appearance Type V Complete tear Complete tear Superior and posterior More severe than type III with coracoclavicular space increased over 100%. Type VI Complete tear Complete tear Inferior Clinical Patients generally complain of tenderness over the AC joint with palpation and range of motion AC joint displacement with gross deformity occurs in the later stages and is usually seen in a type III or greater Provocative tests Cross-chest adduction Passive adduction of the arm across the midline causing joint tenderness Imaging Weighted AP radiographs of the shoulders (10 lbs) – Type III injuries may show a 25% to 100% widening of the clavicular-coracoid area – Type V injuries may show a widening > 100% Treatment Depends on the degree of separation Acute Types I and II – Rest, ice, nonsteroidal anti-inflammatory (NSAIDs) – Sling for comfort – Avoid heavy lifting and contact sports – Shoulder-girdle complex strengthening – Return to play: When the patient is asymptomatic with full ROM Type I: 2 weeks Type II: 6 weeks Types III or greater: Controversial – Conservative or surgical, depending on the patient’s need (occupation or sport) for particular shoulder stability – Surgical: For those indicated (heavy laborers, athletes) – Generally, no functional advantage is seen between the two treatment regimens Types IV to VI – Surgery is recommended: Open reduction internal fixation (ORIF) or distal clavicular resection with reconstruction of the CC ligament 140 MUSCULOSKELETAL MEDICINE Chronic AC joint pain Corticosteroid injection May require a clavicular resection and CC reconstruction Complications Associated fractures and dislocations Distal clavicle osteolysis – Degeneration of the distal clavicle with associated osteopenia and cystic changes FIGURE 4–13. Classification of AC Joint Separations (Anterior Views) (see Table 4–1 for description). MUSCULOSKELETAL MEDICINE 141 AC joint arthritis – May get relief from a lidocaine injection and conservative rehabilitative care should be sufficient GLENOHUMERAL JOINT INJURIES (GHJ) General Glenohumeral joint type: Ball and socket Scapulothoracic motion or glenohumeral rhythm – Balance exists between the glenohumeral and scapulothoracic joint during arm abduc- tion – There is a 2:1 glenohumeral: scapulothoracic motion accounting for the ability to abduct the arm (60˚ of scapulothoracic motion to 120˚ of glenohumeral motion) – The scapulothoracic motion allows the glenoid to rotate and permit glenohumeral abduction without acromial impingement Classification of GHJ Instability Definitions Instability is a translation of the humeral head on the glenoid fossa without complete sep- aration. It may result in subluxation or dislocation Subluxation is a separation of the humeral head from the glenoid fossa with immediate reduction Dislocation is complete separation of the humeral head from the glenoid fossa without immediate reduction Direction of Instability Anterior glenohumeral instability – Most common direction of instability is anterior inferior – More common in the younger population and has a high recurrence rate – Mechanism: Arm abduction and external rotation – Complication may include axillary nerve injury Posterior glenohumeral instability – Less common than anterior instability – May occur as a result of a seizure – The patient may present with the arm in the adducted internal rotated position – Mechanism: Landing on a forward flexed adducted arm Multidirectional Instability – Rare with instability in multiple planes – The patient may display generalized laxity in other joints Patterns of Instability Traumatic: T. T- Traumatic shoulder instability U- Unidirectional B- Bankart lesion S- Surgical management (Rockwood, Green, et al. A- Atraumatic shoulder instability M- Multidirection instability B- Bilateral lesions R- Rehabilitation management I- Inferior capsular shift, if surgery (Rockwood, Green, et al. Bankart lesion (Figure 4–14) Bankart lesion is a tear of the glenoid labrum off the front of the glenoid; this allows the humeral head to slip anteriorly Most commonly associated with anterior instability This type of lesion may be associated with an avulsion of a small fragment of bone from the glenoid rim 2. Hill-Sachs lesion (Figure 4–15) A compression fracture of the posterolateral aspect of the humeral head caused by abutment against the anterior rim of the glenoid fossa Associated with anterior dislocations A lesion that accounts for greater than 30% of the articular surface may cause insta- bility A notch occurs on the posterior lateral aspect of the humeral head due to the recur- rent impingement Posterior dislocations – Reverse Hill-Sachs lesion – Reverse Bankart lesion FIGURE 4–14. MUSCULOSKELETAL MEDICINE 143 Clinical The dead arm syndrome: These symptoms include early shoulder fatigue, pain, numbness, and paresthesias Shoulder slipping in and out of place, more commonly when the arm is placed in the throwing position (abducted and externally rotated) A syndrome of the shoulder and upper extremity usually seen in athletes (pitchers, vol- leyball servers) who require repetitive overhead arm motion Laxity exam: Some patients are double jointed, which is a lay term for capsular laxity. Ask the patient to touch the thumb against the volar (flexor) surface of the forearm. Patients with lax tissues are more likely than others to be able to voluntarily dislocate the shoulder Provocative Tests Anterior Glenohumeral Instability Apprehension test (Figure 4–16) – A feeling of glenohumeral instability on 90˚ of shoulder abduction and external rotation causing apprehension (fear of dislocation) in the patient Relocation test – Supine apprehension test with a posterior directed force applied to the anterior aspect of the shoulder not allowing anterior dislocation. This force relieves the feeling of apprehension Anterior draw (load and shift) – Passive anterior displacement of the humeral head on the glenoid Posterior Glenohumeral Instability Jerk test – Place the arm in 90° of flexion and maximum internal rotation with the elbow flexed 90°. Adduct the arm across the body in the horizonal plane while pushing the humerus in a posterior direction. The patient will jerk away when the arm nears midline to prevent posterior subluxation or dislocation of the humeral head Posterior draw (load and shift) – Posterior displacement of the humerus FIGURE 4–16. If an indentation develops between the acromion and the humeral head, the test is positive. Imaging General films – Routine anteroposterior view (AP) – Scapular Y view – Axillary lateral view Assess glenohumeral dislocations – Others views West Point lateral axillary: Bankart lesions Stryker notch view: Hill-Sachs lesions Treatment Anterior Glenohumeral Instability (T.
However discount avanafil 50 mg mastercard, research using behavioral measures more specific to pain has failed to confirm the presence of age-related differences in children’s longer term generic avanafil 50 mg without a prescription, postoperative pain expression (Chambers, Reid, McGrath, & Finley, 1996). Older children are capable of using validated measures to provide self- reports of pain and there currently exist a number of tools designed to elicit self-reports from children (Champion, Goodenough, von Baeyer, & Thomas, 1998). Using these measures, there are well-documented findings indicating that younger children report more pain from medical proce- dures (e. For example, a study by Good- enough and colleagues (1997) compared needle pain ratings of children aged 3 to 7 years, 8 to 11 years, and 12 to 17 years. Results confirmed that younger children gave significantly higher ratings of pain severity than did older children. Additional research by this group has indicated that age effects in children’s self-reports of pain are predominantly manifested in ratings of sensory intensity, rather than its affective qualities (Good- enough et al. PAIN OVER THE LIFE SPAN 119 A few studies have provided observational assessments of children’s “everyday” pain experiences outside of the clinical realm (Fearon, McGrath, & Achat, 1996; von Baeyer, Baskerville, & McGrath, 1998). Results of this re- search have indicated that young children experience an “everyday” pain event (e. Using a sample of chil- dren aged 3 to 7 years, this research has failed to establish any age-related differences in children’s intensity or duration of pain responses, although increasing age was found to be associated with decreasing help-seeking be- haviors as a result of pain (Fearon et al. Discordance among multiple measures of acute pain in children is not uncommon (Beyer, McGrath, & Berde, 1990), with recent research demon- strating age-related differences in the relationships among different meas- ures of pain in children. Goodenough, Champion, Laubreaux, Tabah, and Kampel (1998) reported that correlations between behavioral and self-re- port measures were strongest for the 3–7-year-olds in their sample and weakest for the 12–17-year-olds. Evidence from research based on both be- havioral and self-report measures appears to indicate that younger chil- dren express and report more pain than older children and adolescents, who are occasionally included in these studies. In summary, data regarding age-related patterns in both chronic pain and acute pain experiences of children are available. Although conclusions regarding age-related differences are sometimes limited due to restrictions in the age range examined, the evidence generally supports that, as chil- dren grow older, prevalence of chronic pain increases. Conversely, re- search examining acute pain reactions indicates that increasing child age is associated with decreased pain and distress. To date, no research has ex- plored potential mechanisms that might account for these contrasting pat- terns; however, it is likely that various complex psychological (e. Research examining the developmental progression of pain experiences and pain-related disability across childhood and into adulthood is needed. Psychosocial Influences on the Experience and Expression of Pain During Childhood McGrath (1994) described a model depicting psychosocial factors that af- fect a child’s pain perception. The model includes consideration of cogni- tive, behavioral/social, and emotional factors. Individual child characteris- tics, including age, are thought to be related to each of these factors, which in turn can influence children’s pain experiences (McGrath, 1994). Cognitive factors include children’s understanding of the cause of their pain, expectations regarding continuing pain and treatment efficacy, the rel- evance or meaning of the pain, and coping strategies (McGrath, 1994). Con- siderable research has examined children’s concepts of general illness from a developmental perspective (Bibace & Walsh, 1980; Burbach & Peter- son, 1986), with most data suggesting that children’s concepts of illness evolve in a systematic, age-related sequence, consistent with Piagetian the- ory of cognitive development. Far less research has examined the develop- mental course of children’s specific understanding of pain. Harbeck and Pe- terson (1992) found, among a sample of children and youth aged 3 to 23 years, that older children and youth had more complex and precise under- standings of pain than younger children. For example, children in the preoperational stage of development were unlikely to be able to offer an ex- planation for the value of pain, whereas children in the formal operations stage were able to acknowledge that pain often carries a preventative or di- agnostic value (Harbeck & Peterson, 1992).