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By E. Kaffu. California Institute of Integral Studies.

A vascular bundle consisting of the Saphenous nerve entrapment presents as medial peroneal artery and veins lies medial to the posterior knee and medial leg pain coreg 12.5 mg visa blood pressure goes up and down. A neurovascular bundle consist- Sural nerve entrapment will present with posterior ing of the tibial nerve order coreg 12.5 mg free shipping blood pressure ranges by age and gender, posterior tibial artery, and veins calf symptoms and can be almost indistinguishable lies in the posterior aspect of this compartment behind from CECS of the superficial posterior compartment. The needle should then be inserted just Lumbosacral radiculopathy should be suspected in posterior to the tibia, closely approximating the pos- athletes with the complaints of leg pain, especially if terior border of the bone. As chronic posterior exertional compartment syndrome, long as not driven too deeply, this approach will keep because of the ischemic etiology in the pathogenesis the needle anterior and medial to the neurovascular of symptoms in both syndromes (Glorioso and structures. J Bone Joint Surg 66-A (9):1415–1420, EXERTIONAL COMPARTMENT SYNDROME 1984. New York, tion of abnormalities in tracer uptake in muscle com- NY, McGraw-Hill, 2001b, p 95. Specifically, the identification of decreased Hutchinson MR, Ireland ML: Chronic exertional compartment postexertional muscle perfusion and radionuclide syndrome––Gauging pressure. Phys Sportsmed 27(5):101–102, concentration in the compartment with increased 1999. Mil netic resonance (MR) imaging in the evaluation and Med 168:48–52, 2003. Martens MA, Moeyersoons JP: Acute and recurrent effort-related diagnosis of CECS (Eskelin, Lotjonen, and compartment syndrome in sports. Sports Med 9(1):62–68, Mantysaari, 1998; Verleisdonk, van Gils A, and van 1990. The theory behind use of MR Matsen FA, Mayo KA, Sheridan GW, et al: Monitoring of intra- imaging is based on the fact that MR imaging is sen- muscular pressure. In CECS, if tissue edema causes pressure ele- dynamic anterior compartment pressures during exercise—A vations in muscle compartments, theoretically postex- new technique using the STIC catheter. Am J Sports Med ercise MR imaging should be able to detect the 10(2):83–89, 1982. Owens S, Edwards P, Miles K, et al: Chronic compartment syn- drome affecting the lower limb: MIBI perfusion imaging as an alternative to pressure monitoring: two case reports. Pedowitz RA, Hargens AR, Mubarak SJ, et al: Modified cri- REFERENCES teria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 18(1): 35–40, Andrish JT: The leg, in DeLee JC, Drez DD, Miller MD (eds. DeLee and Drez’s Orthopaedic Sports Medicine: Principles Rorabeck CH, Fowler PJ, Nott L: The results of fasciotomy in the and Practice, 2nd ed. Philadelphia, PA, Saunders, 2003, management of chronic exertional compartment syndrome. Awbrey BJ, Sienkiewicz PS, Mankin HJ: Chronic exercise Rorabeck CH, Castle GSP, Hardie R, et al: Compartmental pres- induced compartment pressure elevation measured with a sure measurements: An experimental investigation using the miniaturized fluid pressure monitor: A laboratory and clinical slit catheter. Rorabeck CH, Bourne RB, Fowler PJ, et al: The role of tissue Davey JR, Rorabeck CH, Fowler PJ: The tibialis posterior pressure measurement in diagnosing chronic anterior com- muscle compartment––An unrecognized cause of exertional partment syndrome. Samuelson DR, Cram RL: The three phase bone scan and exer- Detmer DE, Sharpe K, Sufit RL, et al: Chronic compartment cise induced lower leg pain: The tibial stress test. Styf JR, Korner LM: Diagnosis of chronic anterior compartment Eskelin MK, Lotjonen JM, Mantysaari MJ: Chronic exertional syndrome in the lower leg. Radiology 206(2):333–337, Verleisdonk EJ, van Gils A, van der Werken C: The diagnostic 1998. Whitesides TE, Haney TC, Harada H, et al: A simple method for Gershuni DH, Yaru NC, Hargens AR, et al: Ankle and knee tissue pressure determination. Arch Surg 110:1311–1313, position as a factor modifying intracompartmental pressure 1975. CHAPTER 23 EXERCISE-INDUCED ASTHMA TESTING 135 The sensitivity and specificity of this test for identify- 23 EXERCISE-INDUCED ASTHMA ing EIA in athletes is approximately 65% (Eliasson, TESTING Phillips, and Rajagopal, 1992; Avital, 2000). Major Fred H Brennan, Jr, DO The challenge should be sport-specific and conducted in the environment in which athletes most commonly experience their symptoms (Brennan, Jr, 2001).

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A cannulated nail contains a threaded pin joint capsule is opened with a ventral Z-shaped incision buy coreg 25mg with mastercard prehypertension young, 221 3 3 buy 12.5 mg coreg amex venice arrhythmia 2013. While the need for prophy- lactic pinning of the opposite side is a matter of dispute, even the authors of one study who consider pinning of the other side to be unnecessary report the occurrence of slip- page on the contralateral side in 40% of cases. Since the load must be taken off the affected side after a slipped capital femoral epiphysis, the load on the contralateral side is increased, resulting in a relatively high risk of slippage on that side as well. In a recent study morphometric parameters were measured to assess the risk of slip of the contralateral hip. In the axial view, control patients had a mean value for the posterior sloping angle of the capital femoral physis of 5 degrees, compared with 12 degrees in unilat- eral and 18 degrees in patients developing bilateral slipped capital femoral epiphysis. The authors postulated that the risk of developing bilateral disease can be predicted by measuring the posterior sloping angle of the capital femo- ral physis in the axial view. Prophylactic pinning of the healthy contralateral side should be recommended only in patients showing an axial posterior sloping angle of the physis of over 12 degrees. AP x-ray of the hips of a 10-year old girl with slipped Complications capital femoral epiphysis and fixation with cannulated screw The following complications are known to occur after reduction, nailing or screw fixation [3, 10, 45, 48]: ▬ chondrolysis, ▬ femoral head necrosis, the dorsal callus is removed while preserving the dorsal premature physeal closure, vessels, and the femoral head is reduced until an adequate infection, offset is restored. The head is Chondrolysis can occur in two ways: fixed with two screws, and the trochanter is also refixed As a result of perforation by a nail or screw. The position of the nail or screw must be checked under the image in- Subcapital wedge osteotomy tensifier in all planes, since it is only visible if the femo- We perform the wedge osteotomy (in contrast with open ral head is struck tangentially by the perforation. An AP reduction) according to Smith-Petersen via an anterior ap- and axial x-ray must also be recorded postoperatively. This Femoral head necrosis is a serious complication of slipped measure also corrects the loss of offset. The femoral neck is capital femoral epiphysis and can occur, for example, narrowed slightly depending on the anatomical configura- if force is used to reduce a chronic case. The advantage of the wedge osteotomy is performed open reduction can also cause this complica- the much reduced risk of femoral head necrosis compared tion. When faced with evidence of a chronic process on that associated with open reduction. If a rotation deformi- the x-ray, the surgeon therefore has to decide whether a ty remains, this can, if necessary, be corrected secondarily reduction can be performed at all, or should only be fixed by an intertrochanteric osteotomy. Otherwise, the subcapital osteotomy represents a in only a third of cases. Of course, a chronically dislocated femoral infection rate in slipped capital femoral epiphysis is no head should not be returned to its original position with higher than for other interventions involving metal im- force, otherwise the risk of femoral head necrosis be- plants. Metal breakage only occurs if excessively thin nails comes much greater. If the history is not clear, we also always attempt a (gentle) reduction since, in the majority of diagnosed cases, Metal removal an acute slippage has already been complicated by a chroni- On completion of growth we generally remove nails and cally dislocated position. Normal screws are difficult to remove as they can particularly important with open reductions. In two cases we have found that the head was avascular even before Correction of the deformity (after completion of the reduction. However, we also have to report two cases of Subcapital wedge osteotomy iatrogenic femoral head necrosis in our own hospital. If the femoral head has slipped by more than 40°, a correc- The surgical technique described by Leunig et al. Although the wedge oste- implement this as close as possible to the deformity, i. Nevertheless, we currently prefer to flexion-valgus osteotomy for the correction of the defor- implement corrections close to the joint. After Southwick described the same opera- Contouring of the femoral neck tion in the English literature in 1967, the technique If ventral protrusion of the femoral neck and resulting is more commonly associated with the name »Southwick« impingement has occurred after only slight slippage, the in the English-speaking world than with the name »Im- impingement can be eliminated by appropriate contour- häuser« (⊡ Fig. This operation represents an alter- ing of the femoral neck (bump resection«). If a relevant native to the subcapital wedge osteotomy, and the risk of labrum lesion is already present (which can be visualized femoral head necrosis is slightly reduced. As a rule, it can by arthro-MRI), the contouring can be performed in also be performed during puberty, even in the florid stage connection with a surgical hip dislocation. Flexion of the femoral neck can If no labrum lesion is present, the contouring can also reduce the anterior impingement, but only to a limited be performed via a ventral approach without surgical hip extent.

Hoffman EB cheap coreg 6.25 mg overnight delivery blood pressure log, Crosier JH buy cheap coreg 12.5mg on line heart attack movie review, Cremin BJ (1993) Imaging in children with spinal tuberculosis. J Bone Joint Surg (Br) 75: 233–9 Calcification of several intervertebral disks, particularly 7. Imhof H, Kramer J, Rand T, Trattnig S (1994) Knochenentzündun- in the cervical and thoracic spine, can occur in small gen (einschließlich Spondylitis). Kayser R, Mahlfeld K, Greulich M, Grasshoff H (2005) Spondylodis- In order to obtain an indication of the distribution of citis in childhood: results of a long-term study. Spine 30:p318-23 tumor types affecting the spine in children and adolescents 9. Laiho K, Savolainen A, Kautiainen H, Kekki P, Kauppi M (2002) The we have been registering cases in the Basel Bone Tumor cervical spine in juvenile chronic arthritis. Malhotra R, Singh KD, Bhan S, Dave PK (1992) Primary pyogenic Reference Center since 1972. J Bone Joint Surg (Am) 74: 278–84 tumors have been registered in under-20-year-olds during 11. Meurer A, Eysel P, Heine J (1995) Ergebnisse der operativen Behan- this time, compared to 183 primary bone tumors in adults. Upadhyay SS, Saji MJ, Sell P, Sell B, Hsu LC (1994) Spinal deformity tumors were malignant (3 Ewing sarcomas, 1 osteosar- after childhood surgery for tuberculosis of the spine. The commonest tumors were osteoblastoma and 91–8 aneurysmal bone cyst, which each occurred in around a quarter of cases. Even giant cell tumor of the sacrum and chordoma, which were fairly common in adults, were extremely rare 3. Osteoblastoma was slightly less predominant in adults than in adolescents, while an- > Definition eurysmal bone cysts were hardly observed in adults at all. Primary bone tumors originating in the vertebral bodies The tumors are distributed very regularly across all or vertebral arches, or soft tissue tumors arising from mu- segments, without any one preferred region. Only the scles, connective tissues, blood vessels or nerve tissues in sacrum is affected to a slightly greater extent (particularly the immediate vicinity of the spine. Osteoblastomas are slightly more likely to affect the lumbar area than the Occurrence thoracic or cervical spine. Only 10% of all primary bone tumors are located in the Of the malignant tumors, osteosarcomas and chon- spine, 85% of which are benign. Diagnoses of primary tumors of the spine in children and adolescents (n=80) compared to adults (n=183) (Basel Bone Tumor Reference Center) Children and adolescents Adults Osteochondroma 3 3. Our register only records tissue infiltration (particularly intraspinal infiltration). In an overview of the European multicenter larly applies to the relatively common spinal tumor of study on the treatment of osteosarcoma (COSS), 22 of osteoblastoma. Out of 975 Ewing sarcomas recorded in Differential diagnosis 3 the European multicenter EICESS study, 78 (8. The common symptom is non-load- Diagnosis related pain that can also occur at night. The laboratory We know from a study on benign tumors of the cervi- results usually indicate whether an infection is present cal spine, that only 70% of the tumors are visible on a or not, but it should be borne in mind that chronic conventional x-ray, even when other imaging techniques infections often show only minimal, or even no, changes have shown a tumor to be present. This also applies to tuberculosis and difficult, therefore, to diagnose tumors of whose existence brucellosis. Severe back symptoms are rare in children and ado- Benign and semi-malignant tumors lescents. In view of the difficulty with radiographic Osteoblastoma diagnosis, a bone scan should be arranged within a Next to aneurysmal bone cysts, osteoblastomas are the reasonable period if the patient complains of pain commonest bone tumors found in the spine in children that is not load-related. Osteoblastomas cause diffuse pain with osteoblastomas of the spine, which were only diag- that frequently occurs at night. As with osteoid osteomas, nosed, on average, some 16 months after the start of the pain responds well to aspirin, although the effect is symptoms.

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Caution must be exercised monary disease is the leading cause of morbidity and with antihistamines in athletes as they can impair tem- mortality as the thick mucus found with CF leads to perature regulation and cause sedation buy coreg 25mg on-line pulse pressure 90. Aerobic exercise has been shown to aid in the clear- Antibiotics are only indicated if progression to a sec- ance of secretions and improve quality of life in ondary bacterial infection occurs buy generic coreg 12.5 mg on-line hypertension 10. Prenatal screening is now available and Athletes with a common cold can continue to partici- should be offered to couples at higher risk, particu- pate to a lesser degree provided no fever is present. Pulmonary Care should be taken to increase hydration and cease function tests are similar to an asthmatic, but also activity if constitutional symptoms occur, such as demonstrate a decreased (FVC). A goal of preventing recurrent respiratory infec- Progression to diseases such as pneumonia and com- tions is attempted through chest physiotherapy, plicated bronchitis warrant up to 10–14 days of rest bronchodilators, and antibiotics. The onset of symptoms typically begins seconds to minutes after the inciting cause. Up to 20% of cases have reaction mediated through IgE antibodies and their a biphasic presentation. It requires previous sensitization and subse- 1–8 h asymptomatic period, a late phase reaction quent reexposure to an allergen. The Anaphylactoid reactions are clinically indistin- late phase symptoms can be protracted, persisting guishable from true anaphylaxis. Both are caused by for several hours in 28% of individuals (Kemp, massive release of potent chemical mediators from 2001). The differences are: ana- phylactoid reactions are not mediated by IgE anti- bodies, they do not require prior sensitization, and they are less commonly associated with severe hypotension and cardiovascular collapse. Both are The diagnosis of anaphylaxis is affected by variability managed with the same treatment measures dis- in the standard case definition. Additional features Anaphylaxis triggers include: food, medications, and include gastrointestinal complaints and experienc- insect stings (see Table 37-7). Any food exposure prior ing a “sense of impending doom” (see Table 37-6). Of special concern would be exposure to the most common food allergens, which include eggs, peanut, cow’s milk, nuts, fish, soy, shellfish, and wheat. Several medications have been known to cause ana- “Sense of impending doom” phylaxis with the most common being beta-lactam antibiotics. Documenting exposure to prescription Tingling/Pruritus medications as well as over-the-counter medications Generalized erythema and supplements is important. Bee-sting sensitivity Urticaria Angioedema Nasal Congestion Rhinorrhea Idiopathic Sneezing Medications Globus sensation Antibiotics Throat tightness IV and local anesthetics Dysphonia Aspirin/NSAIDs Dysphagia Chemotherapeutic agents Opiates Vaccines Dyspnea Allergy immunotherapy sera Wheezing Radiographic contrast media Cough Blood products Latex Hymenoptera envenomation Lightheadedness Foods Syncope Eggs Palpitations Peanut Shock Cow’s milk Nuts Seafood Abdominal cramps Soy Bloating Wheat Nausea/Vomiting Exercise gentle handling Active external rewarming Passive external rewarming active core rewarming a no tissue damage. Clin J Sport Med Clin Sports Med Principles of Manual Medicine, Sports Med Hong Kong J Sport Med Sports Sci Compr Ther J Bone Joint Surg Br Spine Clin J Sport Med SECTION 4 MUSCULOSKELETAL PROBLEMS IN THE ATHLETE DYNAMIC RESTRAINTS STATIC RESTRAINTS CONGENITAL FACTORS water tight closure 279 THE THROWING SHOULDER INTRODUCTION CHAPTER 50 ELBOW ARTICULAR LESIONS AND FRACTURES OLECRANON FRACTURE LATERAL EPICONDYLE FRACTURE PROXIMAL RADIUS FRACTURE DISTAL HUMERUS FRACTURES MEDIAL EPICONDYLE FRACTURE SECTION 4 MUSCULOSKELETAL PROBLEMS IN THE ATHLETE RADIAL NERVE ULNAR NERVE soft knuckles flexor digito- rum profundus cyclist’s palsy, CHAPTER 54 WRIST AND HAND FRACTURES THUMB METACARPAL FRACTURES PHALANGEAL FRACTURES quadrilateral space syndrome 332 1 2 3 4 damage is present (Greis et al, 2002). In general, 80–90% of patients have documented good to excel- Meniscal injury leads to partial meniscectomy in the lent results within the first 5 years after partial menis- majority of cases, as a result of the anatomy of the tear, cectomy (Klimkiewicz and Shaffer, 2002). The popliteal artery, popliteal vein, and tibial nerve are also at risk. Fresh allografts have also been used; bearing alignment, body habitus, age, and activity however, logistical difficulties in the routine use of level (Klimkiewicz and Shaffer, 2002). Early Focuses on sports specific exercises with protected range of motion in a flexible or semirigid a goal to return the patient to sports participation. Protected weight- bearing in an orthosis is allowed with weight bearing to tolerance as soon as possible following injury. Length of time to return to sports is in the form of a short leg cast or brace for 4 weeks, depends on injury grade (see Fig. Early use of cryotherapy has been distal fibula and tibia parallel to the ankle joint. In one study, only 44% of ankle by means of an elastic bandage, felt doughnut, 16 patients had an acceptable outcome at 6 months neoprene or elastic orthosis, or pneumatic device. J Nucl Med deep venous thrombosis 64 Edward S Ashman, MD Brian E Abell, BS, MS IV Am J Sports Med Am J Sports Med Surgery of the Foot and Ankle J Bone Joint Surg Am Clin Sports Med Foot Ankle Int The Textbook of Running Medicine, Orthopaedic Sports Medicine: Principles and Practice Am J Sports Med Am J Sports Med of nonweightbearing immobilization (Arntz, Veith, if present, with medications or compressive stockings and Hansen, Jr, 1988; Myerson, 1989; Kuo et al, as indicated.

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The flow of air also improves donor site dressing care over posterior areas quality coreg 12.5mg heart attack 720p. We use these types of beds for patients with posterior wounds and donor sites cheap coreg 6.25 mg free shipping heart attack heart attack. If using such a bed postoperatively is considered, it should be procured before the operation so that transfer of the patient from the operating room is not delayed. BURN WOUND OPERATIONS The burn wound operation can be conceptually classified into five parts: planning, induction of anesthesia and preparation, excision and hemostasis, grafting, and application of dressings. The Major Burn 235 PICTURE5 Kin-Air air bed with a sand base and air flow through the sand to levitate the patient, thus decreasing pressure and shear forces on the skin. Planning Planning begins with an accurate assessment of the area, depth, and location of the wound. From this assessment, plans can be made as to which areas will be excised and which will just be debrided. Once this is decided, the operation should be scheduled and the necessary items listed above procured. We believe that once a decision is made to operate, further delay in proceeding to the operating room only increases complications. For this reason, we will schedule the operation for the next available time slot, and will usually perform the operation within 24 h of initial examination. The wisdom of this practice has been borne out in the finding that early operations decrease septic complications. Delays greater than this in patients with burns over 40% of the body surface area requiring operation are not indicated regardless of the physiological condition, because the condition is unlikely to improve without ablation of the wound. The discussion should address the typical process of wound healing including those of partial-thickness and full-thickness burns. Deep partial- thickness and full-thickness burns generally will not heal in a timely fashion without operative wound closure, which explains the need for and benefit of the operation. The technical aspects of the procedure should be reviewed, including excision of tissue and planned donor site areas. Risks should also be discussed, including blood loss and the likely use of blood products, risk of infection and development of organ failure, loss of tissue and at times loss of limbs, scarring, pain typically associated with donor site and donor site scarring, and lastly, failure of the operation to achieve its goal (graft loss) generally from technical error. At this time, all questions regarding the procedure and the likely outcomes should be answered. If, after further discussion, this is still the decision of the patient, the time for complete wound closure and the prospect for severe scarring should be made clear, and this should be well documented. Induction of Anesthesia and Preparation When the patient arrives at the operating room, several things should be in place. First, the ambient temperature of the room should be at least 30 C (86 F) because the patient will be mostly exposed for the procedure and will not be able to regulate core body temperature. In fact, it may be necessary to increase the temper- ature further should the patient get cold. Once the patient arrives, anesthesia should be induced with endotracheal intubation. In our practice, we almost always accom- plish intubation by fiberoptic means through the nose. This allows for decreased vulnerability of the airway and for a fiberoptic examination of the upper and lower airways in patients with suspected inhalation injury. Attention then should be turned to placement of intravenous lines and invasive monitors such as arterial lines. We generally, perform operations with a multilumen subclavian venous catheter with one other large-bore venous line. We also place a catheter in the femoral artery to measure blood pressure continuously during the operation and to obtain arterial blood for gas analysis; again, this may not be necessary in cases of smaller burns. An oxygen saturation monitor and continuous electrocardiogram leads should also be placed. We have found that alligator clips attached to staples inserted into the skin work well as electrocardiographic leads instead of adhesive pads. Once the monitors are in place and anesthesia induced, the patient can be prepared for the operation. While the patient is in the supine position, the head The Major Burn 237 should be shaved if the scalp is burned or if the scalp will be used as a donor site.

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