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By A. Nafalem. Oregon Institute of Technology.

The psychiatric patient presenting with panic attack order 160mg tricor amex cholesterol test without fasting, phobia generic 160 mg tricor otc cholesterol test las vegas, or anxiety is reporting a subjective state based on patterns of physiological 68 CHAPMAN signals and not an existential crisis that exists somewhere in the domain of the mind, somehow apart from the body. Similarly, the medical patient ex- pressing emotional distress during a painful procedure, or during uncon- trolled postoperative pain, is experiencing the sensory features of that pain against the background of a cacophony of sympathetic arousal signals. The concept of feedback underscores an essential point: A sensory stim- ulus does not have purely sensory effects. When a neural signal involves threat to biological integrity, it elicits strong patterns of sympathetic and neuroendocrine re- sponse. Sen- sory processing provides information about the environment, but this infor- mation exists in awareness against a background of emotional arousal, either positive or negative, and that arousal may vary from mild to extreme. Nociception and the Limbic Brain Central sensory and affective pain processes share common sensory mech- anisms in the periphery. A-delta and C fibers serve as tissue trauma trans- ducers (nociceptors) for both, the chemical products of inflammation sensi- tize these nociceptors, and peripheral neuropathic mechanisms such as ectopic firing excite both processes. In some cases neuropathic mecha- nisms may substitute for transduction as we classically define it, producing afferent signal volleys that appear, to the central nervous system, like sig- nals originating in nociceptors. Differentiation of sensory and affective processing begins at the dorsal horn of the spinal cord. Sensory transmis- sion follows spinothalamic pathways, and transmission destined for affec- tive processing takes place in spinoreticular pathways. For more detail on the sensory processing of nociception, see Willis and Westlund (1997). Nociceptive centripetal transmission engages multiple pathways: spino- reticular, spinomesencephalic, spinolimbic, spinocervical, and spinothalamic tracts (Villanueva, Bing, Bouhassira, & Le Bars, 1989; Willis & Westlund, 1997). The spinoreticular tract contains somatosensory and viscerosensory afferent pathways that arrive at different levels of the brain stem. Spinoreticular ax- ons possess receptive fields that resemble those of spinothalamic tract neu- rons projecting to medial thalamus, and, like their spinothalamic counter- parts, they transmit tissue injury information (Craig, 1992; Villanueva, Cliffer, Sorkin, Le Bars, & Willis, 1990). Most spinoreticular neurons carry nociceptive signals, and many of them respond preferentially to noxious ac- tivity (Bing, Villanueva, & Le Bars, 1990; Bowsher, 1976). The spinomesen- cephalic tract comprises several projections that terminate in multiple mid- brain nuclei, including the periaqueductal gray, the red nucleus, nucleus cuniformis, and the Edinger–Westphal nucleus (Willis & Westlund, 1997). Spinolimbic tracts include the spinohypothalamic tract, which reaches both 3. PAIN PERCEPTION AND EXPERIENCE 69 lateral and medial hypothalamus (Burstein, Cliffer, & Giesler, 1988; Burstein, Dado, Cliffer, & Giesler, 1991) and the spinoamygdalar tract that extends to the central nucleus of the amygdala (Bernard & Besson, 1990). The spino- cervical tract, like the spinothalamic tract, conveys signals to the thalamus. Central processing of nociceptive signals to produce affect undoubtedly involves multiple neurotransmitter systems. Four extrathalamic afferent pathways project to neocortex: the noradrenergic medial forebrain bundle originating in the locus ceruleus (LC); the serotonergic fibers that arise in the dorsal and median raphé nuclei; the dopaminergic pathways of the ven- tral tegmental tract that arise from substantia nigra; and the acetylcho- linergic neurons that arise principally from the nucleus basalis of the sub- stantia innominata (Foote & Morrison, 1987). Of these, the noradrenergic and serotonergic pathways link most closely to negative emotional states (Bremner, Krystal, Southwick, & Charney, 1996; Gray, 1982, 1987). The set of structures receiving projections from this complex and extensive network corresponds to classic definition of the limbic brain (Isaacson, 1982; Mac- Lean, 1990; Papez, 1937). Although other processes governed predominantly by other neurotrans- mitters almost certainly play important roles in the complex experience of emotion during pain, I emphasize the role of central noradrenergic process- ing and the medial forebrain bundle here. This limited perspective offers the advantage of simplicity, and the literature on the role of central norad- renergic pathways in anxiety, panic, stress, and posttraumatic stress disor- der provides a strong basis (Bremner et al. This processing involves the medial forebrain bundle that subdivides into two central noradrenergic pathways: the dorsal and ventral noradrenergic bundles. Locus Ceruleus and the Dorsal Noradrenergic Bundle Substantial evidence supports the hypothesis that noradrenergic brain pathways are major mechanisms of anxiety and stress (Bremner et al. The majority of noradrenergic neurons originate in the locus ceru- leus (LC). This pontine nucleus resides bilaterally near the wall of the fourth ventricle. The locus has three major projections: ascending, de- scending, and cerebellar. The ascending projection, the dorsal noradre- nergic bundle (DNB), is the most extensive and important pathway for our purposes (Fillenz, 1990). Projecting from the LC throughout limbic brain and to all of neocortex, the DNB accounts for about 70% of all brain nor- epinephrine (Svensson, 1987).

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A r i s e s u p p e r t h o r a c i c b r a n c h s p i n a l a o r t a f r o m s p i n o u s p r o c e s s e s v e r t e b r a e n e r v e s ( b r a n c h ) o f T 1 1 , T 1 2 , L 1 , & L 2 S e m i s p i n a l i s T r a n s v e r s e p r o c e s s e s S p i n o u s p r o c e s s e s o f / s p i n e D o r s a l p r i m a r y T h o r a c i c T h o r a c i s o f T 6 t o T 1 0 C 6 , C 7 , T 1 , T 2 , T 3 , & o p p s i d e b r a n c h s p i n a l a o r t a T 4 n e r v e s ( b r a n c h ) I l i o c o s t a l i s F l a t t e n e d t e n d o n s f r o m I n f b o r d e r s o f a n g l e s / s p i n e D o r s a l p r i m a r y T h o r a c i c L u m b o r u m u p p e r p o r t i o n o f e r e c t o r o f l a s t 6 o r 7 r i b s l a t b r a n c h s p i n a l a o r t a s p i n a e ▼ r i b s n e r v e s ( b r a n c h ) M u s c l e O r i g i n I n s e r t i o n A c t i o n N e r v e A r t e r y S a c r o s p i n a l i s A r i s e s f r o m b r o a d S p l i t s i n t o l o n g i s s i m u s , / s p i n e S p i n a l n e r v e s T h o r a c i c ( E r e c t o r S p i n a e ) t e n d o n a t t a c h e d t o m i d i l i o c o s t a l i s , s p i n a l i s , s p i n e a o r t a c r e s t o f s a c r u m ; a n d s e m i s p i n a l i s ▼ r i b s s p i n o u s p r o c e s s e s T 1 1 m u s c l e s ( s e e r e s p e c t i v e l a t t o T 1 2 a n d l u m b a r m u s c l e s ) v e r t e b r a e ; s u p r a s p i n a l l i g - m e n t t o l i p o f i l i a c c r e s t s a n d l a t c r e s t o f s a c r u m M u l t i f i d u s S p i n o u s p r o c e s s e s o f E a c h a s c e n d s o b l i q u e l y / s p i n e B r a n c h e s o f d o r s a l T h o r a c i c e a c h v e r t e b r a e f r o m c r o s s i n g o v e r 2 t o 4 o p p s i d e p r i m a r y s p i n a l a o r t a s a c r u m t o a x i s. A r i s e s v e r t e b r a e a n d i n s e r t e d n e r v e s f r o m b a c k o f s a c r u m i n t o s p i n o u s p r o c e s s o f f r o m a p o n e u r o s i s o f v e r t e b r a f r o m l a s t l u m b a r s a c r o s p i n a l i s , f r o m m e d t o a x i s s u r f a c e o f p o s t s u p i l i a c s p i n e a n d p o s t s a c r o i l i a c l i g a m e n t s R o t a t o r e s T r a n s v e r s e p r o c e s s o f R o t a t o r e s l o n g i c r o s s / s p i n e B r a n c h e s o f d o r s a l T h o r a c i c o n e v e r t e b r a a n d i n s e r t o n e v e r t e b r a i n t h e i r o p p s i d e p r i m a r y s p i n a l a o r t a a t b a s e o f s p i n o u s o b l i q u e c o u r s e. R o t a t o r e s n e r v e s p r o c e s s o f v e r t e b r a e b r e v e s i n s e r t i n n e x t a b o v e f r o m t h e s a c r u m s u c c e e d i n g v e r t e b r a t o t h e a x i s a n d r u n h o r i z o n t a l M u s c l e O r i g i n I n s e r t i o n A c t i o n N e r v e A r t e r y Q u a d r a t u s S u p b o r d e r s o f t h e I n f b o r d e r o f l a s t ▼ l a s t r i b 1 2 t h t h o r a c i c n. I l i a c c i r c u m - L u m b o r u m t r a n s v e r s e p r o c e s s e s r i b a n d t r a n s v e r s e l a t 1 s t l u m b a r n. S u p r a - p r o t u b e r a n c e ; m e d 1 / 3 c l a v i c l e ; m e d m a r g i n A b d s a m e s i d e C 3 & C 4 s c a p u l a r s u p n u c h a l l i n e ; s p i n o u s a c r o m i o n ; s p i n e o f t h e o p p s i d e s p i n a l n e r v e s p r o c e s s C 7 , T 1 t o T 1 2 s c a p u l a R e t r a c t i o n ▲ g l e n f o s s a ▲ g l e n o i d f o s s a L e v a t o r T r a n s v e r s e p r o c e s s e s M e d b o r d e r s c a p u l a E l e v a t i o n D o r s a l s c a p u l a r n. S u p e r f i c i a l S c a p u l a e C 1 t o C 4 b e t w e e n s u p P r o t r a c t i o n C 3 & C 4 s p i n a l c e r v i c a l a. A b d s a m e s i d e s a m e s i d e R o m b o i d e u s S p i n o u s p r o c e s s o f M e d b o r d e r s c a p u l a E l e v a t i o n D o r s a l s c a p u l a r n. D e s c e n d i n g M i n o r C 7 a n d T 1 a t l e v e l o f t h e s p i n e R e t r a c t i o n s c a p u l a r a. D e s c e n d i n g M a j o r T 2 t o T 5 b e t w e e n s p i n e a n d R e t r a c t i o n s c a p u l a r a. S u b s c a p u l a r D o r s i s p i n o u s p r o c e s s e s o f i n t e r t u b e r c u l a r g r o o v e A b d s h o u l d e r C 6 t o C 8 s p i n a l a. T 6 t o T 1 2 , L 1 t o L 5 , o f h u m e r u s M e d n e r v e s & s a c r a l v e r t e b r a e E l e v a t i o n R e t r a c t i o n P e c t o r a l i s A n t s u r f a c e s t e r n a l 1 / 2 C r e s t o f g r e a t e r s h o u l d e r M e d a n d l a t T h o r a c o - M a j o r c l a v i c l e ; v e n t r a l s u r f a c e t u b e r c l e o f h u m e r u s A d d s h o u l d e r p e c t o r a l n. P e c t o r a l i s E x t s u r f a c e s o f r i b s C a r a c o i d p r o c e s s o f P r o t r a c t i o n M e d p e c t o r a l n. T h o r a c o - M i n o r 3 , 4 , a n d 5 n e a r t h e i r s c a p u l a D e p r e s s i o n a c r o m i a l a. L a t t h o r a c i c A n t e r i o r r i b s 1 t o 9 b o r d e r o f s c a p u l a f r o m D e p r e s s i o n a. C i r c u m f l e x f o s s a ; i n f 2 / 3 g r o o v e o n h u m e r u s & / s c a p u l a r a. S u p r a - f o s s a g r e a t e r t u b e r c l e o f L a t ( w e a k ) s c a p u l a r h u m e r u s ( w e a k ) I n f r a s p i n a t u s M e d 2 / 3 i n f r a s p i n a t u s M i d i m p r e s s i o n o f L a t S u p r a s c a p u l a r n. S u p r a - f o s s a g r e a t e r t u b e r c l e o f A b d a n d a d d s c a p u l a r h u m e r u s T e r e s M i n o r D o r s a l s u r f a c e o f I n f i m p r e s s i o n o f L a t B r a n c h o f a x i l l a r y n. P o s t h u m e r a l a x i l l a r y b o r d e r o f g r e a t e r t u b e r c l e o f A d d c i r c u m f l e x a. P r o f u n d a t u b e r o s i t y o f s c a p u l a ; o f o l e c r a n o n / s h o u l d e r c o l l a t e r a l a. M u s c l e O r i g i n I n s e r t i o n A c t i o n N e r v e A r t e r y L a t h e a d : p o s t s u r f a c e o f A d d s h o u l d e r I n f u l n a r h u m e r u s ; M e d h e a d : p o s t s u r f a c e o f h u m e r u s d i s t a l t o r a d i a l g r o o v e B r a c h i a l i s D i s t a l 1 / 2 o f a n t a s p e c t T u b e r o s i t y o f u l n a ; e l b o w M u s c u l o c u t a n e o u s B r a c h i a l a. I n f u l n a r t o m e d e p i c o n d y l e o f m i d o f l a t s u r f a c e c o l l a t e r a l a. R a d i a l i s h u m e r u s m e t a c a r p a l b o n e R a d i a l P a l m a r i s L o n g u s M e d e p i c o n d y l e o f P a l m a r a p o n e u r o s i s w r i s t M e d i a n n. F l e x o r C a r p i H u m e r a l h e a d : m e d P i s i f o r m b o n e w r i s t U l n a r n. U l n a r i s e p i c o n d y l e o f h u m e r u s ; A d d w r i s t U l n a r h e a d : m e d m a r g i n o l e c r a n o n ; p r o x i m a l 2 / 3 d o r s a l b o r d e r o f u l n a F l e x o r D i g i t o r u m H u m e r a l h e a d : m e d D i v i d e s i n t o 4 t e n d o n s P I P s M e d i a n n. S u p e r f i c i a l i s e p i c o n d y l e o f h u m e r u s ; w h i c h a r e i n s e r t e d i n t o M C P s U l n a r h e a d : m e d s i d e o f t h e s i d e s o f t h e 2 n d w r i s t c o r o n o i d p r o c e s s ; R a d i a l p h a l a n x h e a d : o b l i q u e l i n e o f r a d i u s F l e x o r D i g i t o r u m P r o x i m a l 3 / 4 o f v o l a r & B a s e s o f l a s t p h a l a n g e s D I P s P a l m a r U l n a r a. P r o f u n d u s m e d s u r f a c e s o f b o d y o f P I P s i n t e r o s s e o u s n. F l e x o r P o l l i c i s G r o o v e d v o l a r s u r f a c e o f B a s e o f d i s t a l p h a l a n x I P d i g i t I P a l m a r R a d i a l a. L o n g u s b o d y o f t h e r a d i u s o f t h e t h u m b M C P d i g i t I i n t e r o s s e o u s n. M u s c l e O r i g i n I n s e r t i o n A c t i o n N e r v e A r t e r y P r o n a t o r P r o n a t o r r i d g e o n d i s t a l D i s t a l 1 / 4 o f l a t P r o n a t i o n P a l m a r U l n a r a n d Q u a d r a t u s p a r t o f p a l m a r s u r f a c e b o r d e r a n d p a l m a r i n t e r o s s e o u s r a d i a l o f b o d y o f u l n a ; m e d s u r f a c e o f b o d y o f f r o m m e d i a n n. R a d i a l i s L o n g u s s u p r a c o n d y l a r r i d g e o f o f 2 n d m e t a c a r p a l A b d w r i s t h u m e r u s b o n e — r a d i a l s i d e E x t e n s o r C a r p i L a t e p i c o n d y l e o f D o r s a l s u r f a c e o f b a s e o f / w r i s t R a d i a l n.

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No matter what surgical approach is utilized safe 160mg tricor cholesterol chemical structure, the aim should be to obtain LD50 over 90% TBSA burned (B) purchase tricor 160mg cholesterol definition importance. Other disadvantages include exagger- ated blood losses, prolongation of the hypermetabolic response, and increased risk of infection and sepsis from remaining eschar in which bacteria proliferate. Immediate near-total wound excision has been advocated as an excellent alternative to serial debridement in patients with massive burns. All full-thickness and deep partial-thickness burns are excised within 24 h of admission, and the excised wounds are covered with autografts when feasible and homologous skin grafts or skin substitutes to other areas if the burn exceeds the donor-site supply. Burn eschars are excised completely so that burn wound sepsis is no longer the major cause of death in these patients. Potentially viable tissue, however, may be sacrificed with this technique. It has been postu- lated that the surgical trauma of immediate burn wound excision may aggravate the inflammatory and catabolic response, leading to potentially fatal complica- tions. Furthermore, it is believed that the hemodynamic instability of burn patients during the first 72 h after the injury makes their surgical management more likely to lead to postoperative complications. Therefore, many authors still question the safety and efficacy of immediate burn-wound excision in patients with massive burns, preventing the spread of this technique. Reports from institutions that carry out programs of immediate burn wound excision and sequential burn wound excision have produced LD50 over 90% TBSA burned in children and young adults and over 40% in patients older than 60 years old. No matter the approach used to manage the burn wound, the program should aim for these results. Currently, all young adults and children are candidates for survival (Fig. Use of topically applied silver sulfadiazine plus cerium nitrate in major burns. Effect of cerium nitrate-silver sulphadiazine on deep dermal burns: a histological hypothesis. Topical treatment of serious infections with special reference to the use of a mixture of silver sulphadiazine and cerium nitrate: two clinical studies. Ortega-Martınez´ Hospital Universitario Virgen del Rocıo,´ Seville, Spain INTRODUCTION Resuscitation therapy in burn patients, early nutrition, topical treatment, and pro- phylaxis against burn wound infection and its complications, as performed by a multidisciplinary team of specialists in the burn units, have increased survival of burn patients [1,2]. Psychological support and pain therapy have improved adaptation to the accident, thus decreasing emotional sequelae. The functional repercussions of severe burns on the hands are obvious, and for this reason we believe that their correct treatment is very important. Thermal damage to the hands, patient’s age, and percentage of burned body area requiring grafts are the determining factors of the patient’s ability to return to his or her working situation. Factors that increase the severity of burns of the upper limbs include bilat- eral involvement of hands, from causes such as flames, chemicals, or high-voltage electricity (greater than 1000 V), deep burns involving the dorsum of the fingers, and burns that are circumferential and/or causing inelastic wounds. The primary objective of surgical treatment of burn patients is to increase survival. However, surgery is also necessary to achieve a greater degree of func- tionality of the burned areas, which has a considerable effect on the patient’s life 257 258 Go´mez-Cıa´ and Ortega-Martınez´. Furthermore, burn surgery reduces treatment costs by reducing patients’ length of hospital stay and the number of complications and sequelae. TOPICAL TREATMENT After stabilizing the patient correctly and diagnosing the extent and depth of the wounds and associated lesions, trauma, smoke inhalation, and other factors, we begin treatment with intravenous fluids. Our overall objective is to achieve perma- nent coverage of the burns as quickly as possible. Topical treatment of burned hands is similar to that of the the rest of the body. The first step is to eliminate the causative agent, dissipate the heat, and reduce the temperature of the tissues in the first moments after the accident (cooling also re- duces inflammation and relieves pain). This can be done by profusely flushing the burns (which is especially important with chemical burns), or removing the patient from contact with an electrical source.

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MacKeith buy tricor 160 mg with mastercard cholesterol over 200, Oxford New York The non-invasive imaging technique of sonography is 3 tricor 160mg for sale is cholesterol in shrimp bad for you. Sutherland DH, Olshen RA, Biden EN, Wyatt MP (1988) The devel- based on the interaction between transmitted sound opment of mature walking. In pediatric orthopaedics, sonography is primarily used A CT scanner consists of a gantry that incorporates a for evaluating the infant hip (see chapter 3. It is also rotating x-ray tube and image sensors (detectors), the frequently used in swellings, protuberances and effusions patient table and a computer for processing the data. The CT software converts the x-ray attenuation passing Doppler sonography is used to investigate the circulation through the tissue into a CT density value (known as a in an extremity. The tissue types of bone, muscle, fat and al angiogram is increasingly being superseded these days water can very readily be distinguished from each other by the MR angiogram and by vascular imaging with spiral on the basis of their densities. Myelogra- CT is an indispensable tool for visualizing bony struc- phy is used to visualize intraspinal processes, particularly tures, especially around joints and in the spine, e. The images are either recorded by the conventional reconstruction, in particular, facilitates the evaluation of technique (rarely) or (increasingly nowadays) by com- structures in space (e. Arthrograms are images of the joint interior recorded The newer spiral CT technique enables volumetric after the intra-articular injection of contrast medium. This technique substantially re- having been superseded by arthro-MRI, which is most duces the scanning times, enhances the resolution and fa- commonly performed on the hip for evaluating lesions of cilitates the preparation of three-dimensional reconstruc- the labrum, or on the knee for visualizing separation in tions. Used in conjunction with contrast administration, osteochondrosis dissecans. The main advan- (SPECT ) tages of this technique arise firstly from the simultaneous This new technique has greatly improved the diagnostic imaging of the whole skeleton and, secondly, from the accuracy in the evaluation of bone and joint abnormali- generation of a metabolic picture, i. SPECT offers enhanced contrast resolution com- is shown in comparison with that of adjacent normal pared to conventional tomograms. Widely differing processes can produce a similar Magnetic resonance imaging (MRI) picture. Magnetic resonance imaging (MRI) is based on the re- Scintigrams, or bone scans, offer a suitable screening emission of an absorbed high-frequency signal (RF signal) method for tumors and infections. Technetium (Tc-99m- while the patient remains within a magnetic field gener- MDP) is the generally preferred radioisotope, and indi- ated by a magnet with a magnetic strength of 0. The system consists of the magnet, high-frequency gallium-67-citrate is suitable for confirming therapeutic coils (transmitter and receiver), gradient coils and a digi- success or resistance. If cortical bone appears to be The ability to depict tissues is based on the intrinsic thickened on a plain x-ray, the bone scan can, depending magnetic moment (spin) of atomic nuclei with an odd on the appearance in each case, indicate whether an oste- number of protons and neutrons (e. The atomic nuclei then irregular, uptake) or a stress fracture (localized, but not align themselves parallel to the magnetic field lines. For tumors, scintigraphy beamed pulses of high-frequency radio waves cause the can be used on the one hand to assess the activity of the atomic nuclei to absorb energy, inducing the nuclei to process and, on the other, to scan for metastases. The spin and that nerves and tissues can be distinguished from echo (SE) produces a t1-weighted image with a short other tissue types. Proton-weighted A crucial factor to consider in the application of diag- images have a long repetition time and a short echo time nostic imaging is whether a method requires a high or (⊡ Table 2. The IR sequences (»inversion recovery«) can be used As a matter of principle, therefore, ultrasound and MRI to shorten the scanning times in multiplanar images. If scans are preferred over conventional x-rays and CT a short inversion time (TI) in the range of 100–150 ms scans if the diagnostic result is equivalent. This aspect of is used, the signal intensity of fatty tissues is suppressed. A similar result is also achieved with rastersterography (optical measurement of the back pro- the CHESS sequence(= chemical suppression). Recently, the fat suppression techniques have been has its own radiation protection regulations that form combined with three-dimensional gradient echo imag- ing (GRE = gradient recalled echo), which provides an enhanced view of joint cartilage. Tissue characterization based on the is administered intravenously it is taken up at sites of weighing on MRI images activity, e. Tissue structures can also be seen more clearly after the intra-articular administration of gadolinium.

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Occasionally a radiohumeral bursitis may mimic a lateral epicondylitis (both forms of tennis elbow) cheap tricor 160 mg visa cholesterol problems, but the distinction is of academic interest only purchase 160 mg tricor free shipping cholesterol medication harmful. Ice, heat, nonsteroidal anti-inflammatory medications, physiotherapy modalities, periods of relief from stress and the use of a forearm orthotic generally will result in a satisfactory result within six weeks to three months. Surgery is almost always reserved for patients beyond the second decade with recalcitrant symptoms. Iliotibial band syndrome (“snapping hip”) Iliotibial band tendinitis or “snapping hip” is seen in the teenage–late adolescent. It is almost exclusively found in females, and is a result of a tendinitis directly related to impingement of the iliotibial band across the greater 111 Pain syndromes of adolescence trochanteric ridge. As the pelvis in females expands and widens at the time of puberty, the greater trochanter becomes quite prominent in many females. The iliotibial band will become tautly draped across the greater trochanter and from repetitive flexion-extension and rotation movements of the hip a tendinitis develops at the site where the tendon lies directly adjacent to the greater trochanter. The iliotibial band may thicken and may actually produce a “snapping” or “popping” sensation as the tendon migrates back and forth across the trochanteric ridge. The “snapping” may be even sufficiently audible to frighten the patient into believing the hip is actually dislocating. Diagnosis is readily established by the direct reproduction of symptoms by palpation and compression over the trochanter during hip joint motions (Figure 5. Treatment consists of ice, heat, nonsteroidal anti-inflammatory medications, physiotherapy modalities and periods of restriction of physical activities, particularly those directly related to symptom Figure 5. Point tenderness over greater trochanter at the site of “snapping augmentation. In less than one percent of all cases surgery has been found necessary, and consists of division of the fibers of the iliotibial band that come in direct contact with the greater trochanter. Freiberg’s infraction Freiberg’s infraction, described over 80 years ago, consists of an osteochondritis of the head of the second metatarsal and occasionally the third metatarsal. Histopathologically it has been identified as an avascular necrosis of the metatarsal head. The condition presents as a painful metatarsalgia localized over the involved metatarsal head. Swelling is usually present and the pain is exacerbated by weight bearing and particularly by running and jumping. It is seen at the time of puberty and is Adolescence and puberty 112 more common in the female, with well over three-quarters of all cases occurring in females. The actual etiology is unknown, but it may be related to the peculiar anatomic exposure to stress concentration on the second metatarsal head during repetitive weight bearing stresses in certain foot configurations. The diagnosis is established by standard radiographs, occasionally combined with radionuclide imaging (Figure 5. The natural history is for eventual pain relief to occur in the vast majority of cases regardless of treatment. Treatment is generally indicated because of the significant pain with weight bearing, and consists of brief periods of immobilization in a short leg cast, followed by weight relief from an in-shoe soft orthotic designed to shift weight bearing off the appropriate metatarsal head. Less than 10 percent of the cases become recalcitrant to conservative methods and require surgical treatment. Once the diagnosis is established it is generally acceptable for orthopedic referral to ensue shortly thereafter. Anteroposteriorradiograph demonstrating Freiberg’s infraction “Ingrown” toenails of the second metatarsal head. They are seen equally in both sexes and arise from a consistent etiology. The lateral and distal margins of the medial and lateral portion of the great toenail are allowed to invaginate beneath the skin margins. The paronychial skin then grows over the nail both distally and proximally and incarcerates the nail below and within (Figure 5. Bacteria and debris accumulate beneath the paronychial margins and infection develops, supplemented by repeated trauma from the overlying pressure from the sock and shoe. The paronychial infection blossoms, spreads, and produces erythema, increased edema and exquisite pain. Diagnosis is rarely in doubt, and radiographs should be obtained only to make sure that 113 Pain syndromes of adolescence there is no phalangeal osteomyelitis.

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