By Q. Hamlar. State University of New York College at Oneonta. 2018.
Lastly purchase prednisolone 5mg, we discuss where ultrasound is a weaker alternative to other more com- prehensive methods buy prednisolone 40mg with amex, such as in the detection of periosteal reaction over an area of osteomy- elitis prednisolone 40mg with visa. We do not cover those areas of musculoskeletal practice where ultrasound has no current role order prednisolone 20 mg line. For example safe prednisolone 5 mg, CT and MRI are the most effective means of making a diagnosis of hind- foot coalition, but ultrasound cannot show us the deep structures. X Contents Ultrasound machines vary widely in their ability to realise images of superﬁcial lesions. In musculoskeletal applications most lesions are near the surface and care must be taken to select the best equipment. Even the latest machines may fail in this area, and thorough knowledge of the technology is important to guide our patients to effective diagnosis and treatment. Ultrasound, CT and MRI demand a wide knowledge of anatomy, including variations of normal. Ultrasound is a dynamic examination, and the examiner must also understand the biomechanics and function of the regions studied. The authors of the chapters in this book are all renowned musculoskeletal imaging spe- cialists. They have been briefed to discuss all the imaging appropriate to a suspected diagno- sis, and we hope that the reader will gain an understanding of where each method ﬁts into a modern practice. Oxford David Wilson Contents XI Contents 1 Congenital and Developmental Disorders David Wilson and Ruth Cheung. They abnormally shallow or even dislocated at birth range from isolated defects affecting one part of the but also when a shallow hip fails to mature to one body to complex syndromes with several body sys- that is mechanically stable. Although there is a genetic predispo- and some may cynically suggest that each case is a sition, there is also evidence that abnormal stress new syndrome. However, there are real reasons for on the hip in the later stages of pregnancy may giving as accurate a description as possible. If untreated, a full nosis and outcome may be predictable and there is dislocation will lead to the child failing to walk likely to be concern about the type of inheritance. A shallow and Geneticists will look for as precise a diagnosis as potentially unstable hip may not cause any symp- possible and radiology, especially plain films, is part toms until much later in life when the abnormal of that process (Fig. DDH diagnosed in infancy, by clinical examination and plain film analysis, D. Cheung, FRCR Department of Radiology, Nufﬁeld Orthopaedic Centre, NHS per thousand live births; the incidence of shallow Trust, Windmill Road, Headington, Oxford, OX3 7LD, UK or dysplastic acetabulae is much more frequent 2 D. Cheung The goals of diagnosis and treatment are to permit affected children to walk normally and to prevent premature degeneration. The manoeuvres of Ortolani and Barlow are effective in detecting around 74% of cases of dislocation or subluxation that may be demonstrated on imaging. The level of training and experience required to accurately perform these tests is substantial, and sadly the task is often placed in the hands of the more junior members of the team. There are undoubtedly occa- sions when a child with DDH is overlooked when a clinical abnormality might have been detected by a more experienced clinician. Training and audit of practice are crucial, but even in the best hands there will be errors, as clinical manoeuvres alone are not capable of detecting every case. Indeed it is also likely that some stable hips become unstable, and if the timing of the clinical examination does not coincide with this developing problem then a child may miss the chance of early treatment that could potentially limit or reverse the process. The need for early diagnosis is based on the window of opportunity that exists in the first few months of life when relatively simple treatment may be very effective. Methods range from wearing double nappies to splint therapy and corrective sur- Fig. This examination is part of a full skeletal harder the treatment will be, leading to greater risk survey. There is a real need for a method of diagnosis that is simple, cheap, safe and effective, and US arguably provides such a technique. Unfortunately, the prac- tice of US screening for DDH has developed with no. It is difficult to identify statistics to support randomized control trials to judge its efficacy, and this comment, but experience suggests that per- the only evidence is from observational studies, sisting shallow acetabulae are at least ten times albeit with very large numbers of cases. Whilst many of these children will In early infancy plain films will not show the fem- remodel and spontaneously recover stability, some oral head or much of the acetabulum as these struc- will fail to mature properly and require a variety of tures are not ossified until later in the first year of complex surgical procedures.
Core and surface temperatures in burned patients are elevated to 2 C above normal by a centrally mediated resetting of the hypothala- mus purchase prednisolone 10 mg mastercard. Energy to maintain body heat is provided by futile substrate cycling of carbohydrate and lipids at the expense of protein catabolism quality 10 mg prednisolone. Stable isotope studies have identified simultaneous glycolysis and gluconeogenesis (using amino acids as substrate) discount prednisolone 40mg amex, and continuous cycling of triglycerides and fatty acids discount 20 mg prednisolone free shipping, which expend large amounts of energy in the form of heat quality prednisolone 20 mg. NUTRITIONAL SUPPORT Maintenance of body weight, lean body mass (muscle protein), electrolytes, and vitamin homeostasis are the primary objectives of nutritional support of the burned patient. Without proper nutritional support, hypermetabolic patients can lose up to 25% of their preadmission body weight in the first 3 weeks postburn. Weight loss of up to 30% of body mass was common in burn patients prior to the use of continuous feeding. It is possible to maintain body weight, and/or lean body mass or achieve weight gain, using enteral and/or parenteral nutritional support. It has been demonstrated on many occasions that body weight can be maintained with milk- or soy-based formulations [17–20]. The amount of nutri- tional support required correlates well with resting energy expenditure (REE). REE can be measured directly at the bedside using portable calorimeters that analyze oxygen consumption and carbon dioxide excretion. Formulae have been derived from regression analysis of predicted caloric intake compared with mea- sured weight loss in large patient series, or by direct measurement of metabolic rate using indirect calorimetry. These estimate the energy requirements of patients to maintain body weight. Body weight maintenance has been successfully demon- strated in large numbers of hospitalized patients using these formulae. For an adult, the most commonly used formula calculates caloric needs in burn patients from body weight and TBSA burned. For children, the most appro- priate formula differs with body surface area [21–23] (Table 1). In patients with large burns this can equate to over 5000 kilocalories per patient per day for adults. Although these provide reliable guides, a better estimate of actual energy expenditure is made using a mobile calorimeter at the bedside. Double-labeled water techniques (which enable caloric balance to be studied over time, e. Calories delivered at rates higher than this maintain lean body mass, but stimulate weight gain in patients only through 296 Murphy et al. TABLE 1 Formulae to Estimate Caloric Requirements in Burn Injured Children and Adults Galveston Infant 0-1 year 2100 kcal/m2 + 1000 kcal/m2 burned/day Galveston Revised 1-11 years 1800 kcal/m2 + 1300 kcal/m2 burned/day Galveston 12 years 1500 kcal/m2 + 1500 kcal/m2 burned/day Adolescent Curreri Formula 16-60 years 25 kcal/kg/day PLUS 40 kcal/%TBSA Adult burned/day Curreri Formula > 60 years 25 kcal/kg/day PLUS 65 kcal/%TBSA Seniors burned/day accretion of fat. Optimal nutritional support in convalescent burn patients should be between 1. Skin protein synthetic rates are in- creased, however, with enhanced wound and donor site healing. Milk and the majority of available hospital diets are predominantly fat-based. A high- carbohydrate diet stimulates protein synthesis by increasing endogenous insulin. Enteral nutrition supplied predominantly as carbohydrate and protein (3% lipid, 82% carbohydrate, 15% protein) rather than as fat-based formula (44% lipid, 42% carbohydrate, 14% protein) improves the net balance of skeletal muscle protein in severely burned children. Although body weight can be maintained with a fat-based diet, actual accretion of lean body mass is only achieved using high-carbohydrate, high-protein diets. Muscle protein degradation is de- creased with a high-carbohydrate protein diet due to increased endogenous insulin production. Tight euglycemic control with insulin improves wound healing and decreases infection and mortality [29,30]. The increased nutritional requirements in burn-induced hypermetabolism may be accomplished via enteral or parenteral routes. Nutritional support in se- verely burned patients is best accomplished by early enteral feeding where possi- ble.
The basic prognosis for the clinical condition therefore depends on the extent of the primary neurological damage discount 20 mg prednisolone visa, which also restricts the life expectancy purchase 10mg prednisolone. Twenty-year survival rates of 99% and 50% have been observed for slightly disabled and severely disabled patients respectively purchase prednisolone 10 mg on-line. Regardless of the life expectancy order prednisolone 40 mg fast delivery, the question of the orthopaedic prognosis is frequently raised prednisolone 5mg visa, particularly in respect of the ability to walk. The onset of walking is generally delayed to a greater or lesser extent, however, depending on the severity of the impairment in each case. Walking freely is often difficult for patients with tetraparesis, and ⊡ Fig. Typical crouch position of the only those with mild symptoms will be able to acquire legs with slight internal rotation, good trunk control this skill. In many cases, balance is impaired by deficient trunk and head control to such an extent that the patients required added support (crutches, canes or a walker). In any case, many patients are at least able to achieve a trans- fer function in this way. Only the most severely disabled patients are hardly able to walk or stand at all, although here too any prognosis should be made very carefully. It is often asserted that walking can no longer be learned after the age of seven. Clinical experience has taught us, however, that it is perfectly possible to achieve a certain ability to walk beyond this age. One needs to define »walking« in this context: It is, of course, highly unlikely that patients of this age will be able to acquire the walking ability of neurologically normal individuals. The important point is that they can learn how to move their own weight over a few meters, perhaps only with support. The chances of acquiring such a limited walking function at this stage are particularly good if any existing orthopaedic deformities such as hip dislocations or severe contractures can be corrected. Since a motor-related prognosis is unreliable in this context, we are particularly circumspect when mak- ing any statements, particularly negative ones. Bluntly in- forming parents that »your child will never learn to walk« is demotivating and jeopardizes many therapeutic steps. The leg on the affected side is internally rotated and the knee and hip are flexed. In contrast with the situation for cerebral palsy, a fairly pronounced and troublesome spasticity develops. As a result, some Myelomeningocele involves a cleft malformation in astonishing results are occasionally achieved despite the which the vertebral arches are not closed, the dura 4 presence of severe damage. Treatment is based on the either protrudes in a sack-like manner or is simply ex- principles described in chapter 4. Neurological function is impaired at the References level of the myelomeningocele and distally. Anonymous (2002) Prevalence and characteristics of chil- tion (usually as flaccid paralysis), sensitivity and bladder dren with cerebral palsy in Europe. Beckung E, Hagberg G (2002) Neuroimpairments, activity limi- Synonyms: Spina bifida tations, and participation restrictions in children with cerebral Common abbreviation: MMC palsy. Coniglio SJ, Stevenson RD, Rogol AD (1996) Apparent growth Myelomeningocele is the most common disorder of the hormone deficiency in children with cerebral palsy. Hutton JL, Cook ET, Pharoah PO (1994) Life expectancy in chil- cleft malformation is not known, a multifactorial pro- dren with cerebral palsy. Br Med J 309: 431–5 cess is probably involved: Myelomeningocele, together 7. Liu J, Li Z, Lin Q, Zhao P, Zhao F, Hong S, Li S (2000) Cerebral palsy and multiple births in China. Int J Epidemiol 29: 292–9 incidence is observed in the lower social classes. Nordmark E, Hagglund G, Lagergren J (2001) Cerebral palsy in is also important, and folic acid in particular is known to southern Sweden I. The fre- atr 90: 1271–6 quency of neural tube defects appears to be on the decline 10. A myelomeningocele can develop either as a result A review of population studies in industrialized nations since 1950.
Von Laer L cheap prednisolone 40 mg without a prescription, Gruber R prednisolone 10 mg with amex, Dallek M purchase prednisolone 5mg mastercard, Dietz HG prednisolone 5mg discount, Kurz W cheap prednisolone 20 mg visa, Linhart W, Marzi Metreweli C (2001) Acute elbow trauma in children: spectrum of I, Schmittenbecher P, Slongo T, Weinberg A, Wessel L (2000) Clas- injury revealed by MR imaging not apparent on radiographs. The human child, however, starts walking with an »unnatural« extended hip position and must compensate for the increased anteversion 4. Sometimes the mother and father do the hips of the human fetus are in a flexed position in the not spontaneously decide to consult the doctor, but only womb. The centering of the femoral head during increased do so after being alerted by a well-meaning grandmother or neighbors, or even a shoe sales assistant. They bring their child to the office and ask anxiously whether their child with the twisted feet is really normal. Occasionally, the child may also be bow-legged or, if slightly older, have pronounced knock knees, which just serves to deepen the worry lines on the parents’ faces even more. For this reasons, a detailed review of the rotational and axial rela- tionships in children is appropriate. Terminology Since terms are often mixed up and used incorrectly, ⊡ Table 4. Normal development of axial and rotational relationships in the lower extremities A knowledge of the normal development of axial and rotational relationships is crucial in order to be able to ⊡ Table 4. Terms associated with axial and torsional deformities Term Meaning Torsion Rotation of the anatomical axes of the two end points of a bone in the frontal plane in relation to each other Rotation Movement of a joint around a fixed axis of rotation Valgus Axial deviation towards the central axis of the body in the frontal plane Varus Axial deviation away from the central axis of the body in the frontal plane Femoral anteversion Angle between the femoral neck axis and the frontal plane towards the front Retroversion Pathological torsion posteriorly of the femoral neck in relation to the frontal plane Genu valgum Valgus deviation of the lower leg in relation to the upper leg (knock knees) Recurvated knee Hyperextensibility of the knee by>10° Genu varum Varus deviation of the lower leg in relation to the upper leg axis (bow legs) Bowed leg Medial bowing of the distal part of the lower leg Medial torsion of the tibia Torsion of the lower leg with a malleolar axis of less than 10° at the age of over 5 years Lateral torsion of the tibia Lateral torsion of the lower leg with a malleolar axis of more than 40° in relation to the knee condyle axis Derotation osteotomy Usual term for a correction of the torsion of the upper or lower leg; a more correct term would be detor- sion osteotomy 548 4. Axes and tor- A physiological varus leg axis exists at birth, in the sense sions undergo typical changes as the infant develops into of a bowed leg rather than a genu varum. The knee should be in a neutral position each other in the thigh, lower leg and foot. Thus the char- at the start of walking, but then subsequently develops a acteristic flat valgus foot position of the toddler depends valgus position of approx. The exaggerated valgus position Expressed in rather simplified terms, the flat valgus foot corrects itself by the age of 10 to the physiological valgus represents an attempt by the child to correct the inward- position of 5–7°, which we experience as a »straight« leg 4 facing position of the foot resulting from the increased axis, with both the femoral condyles and malleoli touch- anteversion of the femoral neck. A more specific distinction is pos- The average anteversion at birth is approx. We then creases during growth to a final angle of 15° in adulthood observe the axes in standing. Slightly higher angles are measure the intercondylar distance and, in genu valgum, found in girls compared to boys. The position of the hip is an indirect expression of the degree of anteversion. Ex- At birth, external rotation is usually higher than internal ternal and internal rotation are determined on the prone rotation, whereas the opposite is the case after the child patient with the hip extended ( Chapter 3. With the patient still in the prone position we Femoral Neck-shaft angle in the frontal plane measure the torsion of the malleolar and foot axes com- The femoral neck-shaft angle is approx. Tibial torsion Tibial torsion refers to the rotation of the malleolar axis in relation to the back of the tibial condyle at knee level. A lateral torsion of 15°, on average, develops during the first few years of life. Tibial torsion can also be expressed by the angle between the axes of the foot and thigh ( Chapter 3. Knee axis (a) and intermalleolar / intercondylar distance sion of the tibial torsion) during growth. Right When the feet are rotated outwards the kneecaps point straight ahead be allowed to rotate, since it can easily rotate inwardly or outwardly at the ankle. It should be at right angles to the lower leg and should adopt its spontaneous position in respect of rotation. Imaging procedures Anteversion (AV) can be determined by various methods. Anteversion can also be determined with almost equal precision by means of ultrasound. However, if an abnormal condition requir- ing treatment is not suspected, clinical measurement will also suffice ( Chapter 3. To this end, slices must be recorded through both femoral necks and both femoral condyles at knee level (⊡ Fig. It should be noted, however, that the anteversion angle on the CT scan is not measured in space but rather in the horizontal plane, which is not exactly the same.
The phenomenon of intelligent nonadherence buy 10mg prednisolone fast delivery, when the bene- fits are outweighed by the costs of taking the drug prednisolone 40mg without prescription, must also be recognized and addressed purchase prednisolone 40 mg with mastercard, or the physician is rendered ineffective by the patient’s in- complete account of his or her behavior prednisolone 5 mg without a prescription. Physicians’ and patients’ esti- mates of the extent of barrier to use presented by particular adverse effects differ substantially cheap prednisolone 20 mg without prescription. Therefore, eliciting the report of an adverse effect (such as dry mouth with tricyclic antidepressants) should be followed by investi- gation of its implications (such as avoiding social conversation). The cognitive approach that estimates the personal costs and benefits of adherence to recommended physical exercises may also be useful, al- though the area presents some different problems. Physiotherapists often offer too much rather than too little information (so that desirable adher- ence is hard to measure) (Sluijs, Kerssens, van der Zee, & Myers, 1998), and enjoyment of the exercise may be an important factor in maintaining exer- cise regimens (Jones, Harris, & McGee, 1998). That would suggest that intro- ducing the patient to as many as possible sports, exercise routines, and even energetic leisure activities, such as some types of dance, may encour- age adherence by finding at least one that he or she enjoys. However, ad- herence to exercise by the healthy population is notoriously low over months, and practical issues of access to facilities play an important part (Sallis & Owen, 1998). PSYCHOLOGICAL INTERVENTIONS AND CHRONIC PAIN 293 Adherence to pain management methods both during and after treat- ment programs is somewhat underresearched, and little evidence has so far accrued that can identify the extent of adherence necessary to ensure maintenance of treatment gains or improvement on them. Research evi- dence suggests that complete adherence is not necessary for a positive treatment outcome (Silver, Blanchard, Williamson, Theobold, & Brown, 1979), but rather that gains may be greater among those with the highest adherence (Parker et al. Causes of nonadherence to pain manage- ment programs have been investigated (Turk & Rudy, 1991), but measure- ment of nonadherence itself is complicated in that patients often adhere to some aspects of a program and not others (so cannot be simply divided into adherents and nonadherents for comparison). Results of this research suggest that adherence is generally low among patients (e. As noted by Turk and Rudy (1991), hundreds of variables have been studied in relation to adher- ence, and not surprisingly the results are inconsistent, with contributions to variance from components of treatment program, the injury, the pro- vider–patient relationship, social support, and patient characteristics (see Turk & Rudy, 1991). Given this evidence, psychologists can play an important role in promot- ing adherence to treatment regimens, whether the treatment is medication, physiotherapy, or other components of pain management. Four general strat- egies exist: (a) assisting the patient in modifying the environment to facilitate adherence (e. Efforts to address at least some of these dimensions have resulted in improved outcomes (Hol- royd et al. The other area where psychologists at times assist is the selection and preparation of patients for surgery. Although there is lots of evidence for psychological preparation for surgery helping a range of outcomes (e. Carragee (2001) reviewed the literature and concluded that psychological screening prior to disc surgery is of limited value in many cases, and can be viewed as useful only when less pathol- ogy is present, there have been longer periods of disability, and economic issues are present. Other variables, such as internal locus of con- trol and lower catastrophic cognitions, have also been associated with better outcomes, such as shorter time to achieve a straight leg raise follow- ing total knee replacement (Kendell, Saxby, Malcolm, & Naisby, 2001). The research is correlational in nature and does not rule out the possibility that patient anxiety reflects a realistic interpretation of the circumstances sur- rounding surgery. It is also possible, however, that anxiety serves to limit activity and thus reduces the probability of a positive outcome. In line with this interpretation, concurrent psychological intervention with surgery may serve to enhance surgical outcome. That is, psychological interventions specifically aimed at anxiety reduction and improving self-efficacy and con- trol may serve to facilitate recovery in some patients. In particular, usage of imagery and relaxation strategies following surgery was associated with significantly greater knee strength, and less pain anxiety about reinjury. Overall, there appears to be increasing support for psycho- logical interventions in improving outcomes following surgery, but clearly more research is needed in this area. PAIN IN CHILDREN Prior to concluding, it must be acknowledged that this chapter, due largely to space constraints, has focused on psychological interventions for adults with chronic pain. We recognize that psychological interventions are also used to manage pain among children and adolescents (McGrath & Hillier, 1996; see also chap. Cognitive interventions with children typically focus on modifying thoughts and coping abilities related to pain (e. McGrath (1987), in particular, strongly advocated a multistrategy approach (both pharmaco- logical and nonpharmacological) for optimal management of recurrent per- 10. PSYCHOLOGICAL INTERVENTIONS AND CHRONIC PAIN 295 sistent pain that is tailored to the child and follows from the needs identi- fied through a multidimensional pain assessment. The interested reader is encouraged to review Eccleston, Morley, Williams, Yorke, and Mastroyan- nopoulou (2002), who conducted a recent systematic review and meta- analysis that shows good efficacy, but only really for headache, and second- arily for abdominal pain and sickle cell where there has been some prelimi- nary research. There is no controlled research on several major childhood chronic problems such as juvenile rheumatoid arthritis. CONCLUSION Although psychological treatments for chronic pain have been shown to be valuable, there is far greater support for CB interventions than any other form of treatment.
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