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By K. Vatras. Truman State University. 2018.

Torus fracture:A cortical deformity caused by compression and is usually metaphyseal in loca- tion order hydrochlorothiazide 25mg with amex. Lead pipe fracture: An incomplete transverse fracture of one cortex with an associated buckling of the opposite side order hydrochlorothiazide 12.5 mg on-line. Plastic bowing fracture: Occurs as a result of deformation forces exceeding the elastic strain capability of the bone hydrochlorothiazide 25mg discount. Although an obvious fracture may not be generated hydrochlorothiazide 25mg generic, the bone appears bowed (bent) throughout its length hydrochlorothiazide 25 mg lowest price. Toddler’s fracture:A non-displaced oblique fracture, usually of the tibial shaft, that typically is only seen on one radiographic projection. It occurs in children between the ages of 1 and 3 years and is thought to be a result of the torsional forces that occur when the young child grips the floor with their toes when learning to walk. The epiphyses The epiphyses are the secondary ossification centres related to bone growth. Epi- physeal injuries result from shearing forces directed through the epiphyseal plate, avulsive forces focused through the ligamentous and joint capsular attach- ments and vertical forces directed to the centre of the epiphysis. Accurate iden- tification of an epiphyseal injury is essential because of its association with bone growth disturbances and possible failure of the bone to form the correct shape or joint relationships2. Bone Physeal growth Humerus Proximal = 80% Distal = 20% Radius Proximal = 25% Distal = 75% Ulna Proximal = 20% Distal = 80% Femur Proximal = 30% Distal = 70% Tibia Proximal = 55% Distal = 45% Most epiphyseal injuries occur between the ages of 10 and 16 years (with the exception of the distal humeral epiphysis where most injuries are noted in chil- dren under 10 years of age). The likelihood of an epiphyseal injury adversely affecting bone growth is dependent upon its type and site, as the rate of physeal growth is not consistent within the body (Table 7. The most commonly used system for classifying physeal fractures is the Salter-Harris classification system (Table 7. The management of physeal injuries varies from simple immobilisation to complex surgical procedures. Essentially, Salter-Harris type I and type II injuries will retain an intact epiphysis and can be treated by closed immobilisation fol- lowing minimal reduction. Salter-Harris type III and type IV injuries may require surgical intervention as the epiphyseal fragments are separate and mobile. Salter- Harris type V injuries cannot be treated directly as these injuries result from physeal compression and the subsequent closure of the growth plate prevents further growth. In these patients, regular growth assessment will be necessary to evaluate any limb length discrepancy. Upper limb injuries The clavicle The fracture and dislocation of the clavicle is a frequent childhood shoulder injury, particularly in children under 10 years of age. The injury pattern is typi- cally a greenstick fracture of the middle third of the clavicle with no associated ligamentous damage (Fig. Occasionally, in 5% of injuries, a fracture of the outer third of the clavicle may be seen and any displacement at this site is sug- gestive of coracoclavicular ligamentous damage. The coracoclavicular and acromioclavicular ligaments hold the clavicle in position and damage to these ligaments can result in clavicular subluxation or dislocation2 (Box 7. Salter-Harris type Features Diagram I Separation of the metaphysis and epiphysis which is seen radiographically as misalignment or widening of the physis Accounts for 6–8% of injuries and is most commonly seen in children under 5 years of age II Separation of physis (with or without misalignment) plus a metaphyseal fracture Commonest fracture pattern and accounts for 70% of injuries Most frequently seen in distal radius injuries and in children over 8 years of age III An intra-articular fracture through the epiphysis which results in a separated epiphyseal fragment Accounts for 7% of injuries and is commonly seen in the distal femoral and tibial epiphyses IV An intra-articular fracture through the epiphysis, physeal plate and metaphysis Accounts for approximately 12% of injuries and is most frequently seen in the lateral condyle of the humerus V Compression of the physis which has serious prognostic consequences This is the most serious physeal injury and accounts for 0. It is most commonly seen in the distal tibia and femur but can be difficult to identify, particularly after fusion across the physis has begun in adolescence 134 Paediatric Radiography Fig. Type 1: Spraining of the acromioclavicular ligaments with no movement of the clavicle. Type 2:T earing of the acromioclavicular ligaments with coracoclavicular ligaments remaining intact. Minimal malalignment may be seen with displacement of the acromioclavicular joint of up to half the thickness of the clavicle. Type 3:T earing of both the acromioclavicular and the coracoclavicular ligaments with possible associated avulsion of the coracoid process. The acromioclavicular joint is widened and the clav- icle is seen above the level of the acromion process. The scapula The scapula is rarely fractured owing to its thick covering of muscles and there- fore significant force is necessary to cause injury (e. The secondary ossification centres on the lateral aspect of the acromion can cause confusion and it is important to remember that they do not appear until between the ages of 15 and 18 years and can be fragmented in appearance. The glenohumeral joint Dislocation at the glenohumeral joint is rare in children as the proximal humeral growth plate forms a natural line of weakness and will transmit any force to gen- erate a Salter-Harris type injury. However, if a true dislocation does occur, it is likely to be in an anterior direction (97% of cases) following a fall on an out- stretched hand. Humeral shaft fractures will commonly occur following direct trauma and may have an asso- ciated open wound whereas transverse, oblique and spiral fractures are gener- ated by indirect forces.

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J cia lata generic 25mg hydrochlorothiazide with visa, and b) positioning the knee intermittently Pediatr Orthop 21:148–51 in 90° hip and knee flexion for several days postop- 14 generic 25mg hydrochlorothiazide free shipping. Silber JS buy discount hydrochlorothiazide 25mg on line, Flynn JM (2002) Changing patterns of pediatric pelvic eratively (using a foam block) cheap 25mg hydrochlorothiazide visa. Pierre P hydrochlorothiazide 25mg on-line, Staheli LT, Smith JB, Green NE (1995) Femoral neck Pin-track infections can be expected to occur in pa- stress fractures in children and adolescents. J Pediatr Orthop 15: tients with external fixation in 5%–10% of cases, 470–3 even with a good standard of care/instruction. Trueta J (1957) The normal vascular anatomy of the human femo- seropurulent secretion and reddening at the pin in- ral head during growth. Oral broad- 7: 615–24 spectrum antibiotics, daily baths or showers and local 18. Weinberg AM, Hasler CC, Leitner A, Lampert C, Laer L (2000) Ex- pin care usually reduce the inflammation promptly. Treatment and Only in rare cases does the skin incision need to be results of 121 fractures. The frequency peaks around the age > Definition of 5 or 6, but it can also affect children at any age be- Transient synovitis is a hip joint effusion that occurs in tween 1 and 12/13. The annual risk of transient small children in connection with other illnesses (e. Transient synovitis is a symptom rather than the children affected subsequently experienced a second a separate illness. Another study in Ger- ▬ Synonym: Toxic synovitis many calculated an annual incidence of approx. A recurrence risk of 15% was determined in a Brit- Etiology ish study. Since transient synovitis occurs as a symptom in asso- ciation with other, usually viral, infections, there is no Clinical features, diagnosis uniform etiology [1, 16, 24]. It involves a reaction to a The joint effusion causes pain, which manifests itself as process outside the hip, most commonly a viral in- limping and restricted hip movement. Depending on the fection of the upper respiratory or gastrointestinal tract. Ultrasound studies have shown that a (slight) effusion spontaneous limp. The children with transient synovitis is also present, without producing symptoms, in the other are always healthy and are not feverish, nor do they have hip in around a quarter of cases. Confusion There has been much discussion as to whether Legg- can be caused by cases that are superimposed by a current Calvé-Perthes disease can develop from transient sy- viral infection with subfebrile temperatures (e. This idea was postulated in the 1980’s, but has upper respiratory tract. While Legg-Calvé-Perthes disease may be ac- persist or recur without treatment or after the discontinu- companied by an effusion, the underlying disease itself ation of anti-inflammatory measures for periods exceed- can already be diagnosed at this stage sonographically ing two weeks. But even these children are invariably (on the basis of cartilage thickening) and radiologically in good health with no clinical signs of a serious illness. The effusion is never the cause but, at most, distinct limp and significant restriction of hip mobility, a concomitant symptom of the Legg-Calvé-Perthes initially in terms of flexion/extension, subsequently ex- disease. The limp usually occurs spontaneously, sient synovitis, Legg-Calvé-Perthes disease did not subse- although transient episodes of limping during the 10 days quently occur in a single case. While a femoral head preceding the initial consultation are also sometimes necrosis can be generated experimentally in animals by reported. What is striking, although this cannot differentiate between a serous effu- however, is the fact that children with transient synovitis sion and pus. An American study has Crohn’s disease and ulcerative colitis, shown that four parameters can be used to diagnose a multiple epiphyseal dysplasia, purulent process in the hip: slipped capital femoral epiphysis. The validation of these statements has Bone scan: osteomyelitis, soft tissue disorders associ- shown contradictory results in two recent studies [15, 18]. We consider C-reactive protein (CRP) to be a more suit- Laboratory: leukemia, infections (blood culture, CRP, able parameter than erythrocyte sedimentation since the erythrocyte sedimentation, differential white blood latter reacts more slowly to an infection. The white cell count and the CRP (or the eryth- The following therapeutic options are available for tran- rocyte sedimentation rate) must be determined sient synovitis: in every child with hip pain and restricted hip Resting the hip, movement. A delay in the diagnosis of a single Aspiration, case of septic arthritis of the hip is not justified Analgesics/anti-inflammatory drugs.

Fibrous dysplasia is a sporadically occurring benign bone dysplasia in which fibro-osseous tissue begins replacing the interior of bones and may also affect extraskeletal sites trusted hydrochlorothiazide 25 mg. It is likely that a failure of conversion woven into lamellar bone exists buy cheap hydrochlorothiazide 25 mg on line. It is commonly seen in three different forms: a monostotic (single bone) type hydrochlorothiazide 25mg on-line, a polyostotic monomelic type in which multiples bones within a given extremity are involved cheap hydrochlorothiazide 25 mg amex, and a polyostotic generalized form that is commonly associated with precocious puberty (Albright’s disease) cheap hydrochlorothiazide 25 mg on-line. Although etiology is unknown, primitive fibrous tissue begins replacing the medullary cavity, expanding the bone from within. The disorder affects both long bones and flat bones, and, not uncommonly, the bones of the skull Miscellaneous disorders 136 and face are involved. Clinical findings depend on the location within the bone or bones, and the presence of fracturing. Pain, limping, bowing, and shortening are the usual symptoms encountered. Because of the markedly disturbed and weakened internal architecture of the long bones, fracturing is common. Cafe-au-lait spots are often seen in´ association, and have an irregular margin unlike those seen in neurofibromatosis. The presence of sexual precosity is most common in females and is quite striking in nature. Characteristically on standard radiographs the lesions of fibrous dysplasia produce a “ground glass” consistency (Figure 6. Although the location is generally metaphyseal, the lesions tend to spread into the diaphysis, producing expansion of the cortex and increasing deformity. Characteristically a “shepherd’s crook” deformity occurs in the Figure 6. Anteroposterior radiograph showing characteristic changes upper end of the femur and is quite within the tibia and fibula of fibrous dysplasia. Anteroposterior radiograph showing characteristic “shepherd’s during the period of growth, progression is crook” deformity seen in fibrous dysplasia. There is little risk of malignancy, as malignant transformation has been estimated as less than one half of one percent. Appropriate orthopedic referral is indicated once the diagnosis is established. Most patients will develop problems relative to the bony involvement such as angular deformity, scoliosis, and limb length inequality. Pathologic fractures are managed in a conventional orthopedic fashion and healing is to be anticipated. Hemangiomatosis and lymphangiomatosis Hemangiomatosis and lymphangiomatosis are hamartomatous lesions of primarily the deep soft tissues that by their presence affect the size, shape, and length of the limbs. The lesions 137 Osteochondroma may consist primarily of hemangiomatous type tissue, or of tortuous dilated lymphatic channels, most likely arising from a common cellular origin (Figures 6. Clinically, patients so affected may present with pain in the extremity, but more usually as a result of regional gigantism, leg length discrepancy, and limb deformity. Well defined, rounded calcifications (phleboliths) may be seen on radiographs. In more involved cases an entire limb or an entire portion of the body may be involved with these slowly enlarging lesions. The clinical manifestations usually require a combination of plastic surgery and orthopedic surgery. Osteochondroma (osteochondromatosis) The basic lesion of osteochondroma or osteochondromatosis is a benign cartilage capped protrusion of osseous tissue arising Figure 6. Anteroposterior radiograph showing extensive calcification and from the surface of bone. The cortex of the fusiform enlargement of the soft tissues in hemangiomatosis. Computed tomography images showing markedly enlarged the base of the lesion. Although the lesion angiomatous lesions in the soft tissue with calcification in hemangiomatosis. It is best conceived as the body’s attempt to form an additional bone in an abnormal location. It is likely that these lesions arise as an aberration in the direction of growth within the peripheral portion of the epiphyseal growth plate, producing a bone that then proceeds to grow along the path of least resistance.

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Pain at the ball of the foot may be a contusion or stress fracture of one of the sesamoid bones purchase 25 mg hydrochlorothiazide with visa. If the patient has plantar fasciitis buy hydrochlorothiazide 12.5 mg mastercard, the patient will give a history of insidious onset of medial plantar heel pain that begins on taking the first step of the morning order hydrochlorothiazide 12.5mg without prescription. Classically generic hydrochlorothiazide 25 mg without prescription, the pain alleviates after a few steps but tends to return later in the evening best 25 mg hydrochlorothiazide. Patients with sesamoiditis complain of pain that began or became more pronounced during jumping or pushing off to run. Patients with calcaneal or retrocalcaneal bursitis may complain of pain with running. Patients with stress fractures complain of pro- gressively worsening pain that usually is precipitated by an increase in activity intensity. For example, if the patient begins training for a marathon and is running more than usual, the patient may develop a stress fracture. Patients with an interdigital neuroma, metatar- salgia, hallux valgus, or hallux rigidus may complain of pain that began with a change in footwear. An insidious onset of intractable heel pain is indicative of tarsal tunnel syndrome. Patients with tarsal tunnel syndrome will complain of numbness and burning in addition to pain behind the medial malleolus and at the sole of the foot. Other important questions to ask include: What makes the pain better or worse? These questions are most helpful when deciding on imaging studies and treatment. Physical Exam Having completed taking your patient’s history, you are ready to perform your physical exam. Next, palpate the patient’s foot beginning with the first digit (hallux). Instruct the patient to dorsiflex as you dorsally palpate the first digit. Tenderness and decreased range of motion of the first metatarsalphalangeal (MTP) joint may indicate hallux rigidus. Pain elicited by resisted plantarflexion of the first digit may indicate flexor hallucis longus tenosynovitis. Tenderness to pal- pation over the fifth MTP indicates a Jones fracture, until proven oth-erwise with radiographs. Squeezing the metatarsal bones together while simultaneously pal- pating a painful web space is the compression test for interdigital neu- roma. If an interdigital neuroma is present, the involved web space should be tender to palpation with this maneuver. Allow the patient’s history to further guide your physical examina- tion. Palpate the bones of the foot, paying particular attention to any painful areas. Tarsal tunnel syndrome may cause pain, tingling, burning, and/or numbness in the sole of the foot. This exam and the management of this syndrome are discussed in Chapter 7. Passive dorsiflexion will stretch the plantar fascia and pain with this maneuver reveals plantar fasciitis (Photo 2). Medial heel tenderness at the plantar fascia attachments may also indicate plantar fasciitis. Part of the physical examination of a patient with foot pain includes examining the patient’s footwear. As you examine the footwear, ask yourself the following questions: are the shoes causing the foot pain? Plan Having completed your history and physical examination, you have a good idea of what is causing your patient’s foot pain. Treatment: Conservative care includes shoes with a wide toe-box and orthotics. Surgical excision of the deformity is reserved for severe cases that do not respond to conservative care. Foot Pain 125 Suspected retrocalcaneal bursitis Additional diagnostic evaluation: X-rays, including standing AP and lateral views, may be obtained.

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Impulse conduction properties of noradrenergic locus coeruleus axons projecting to monkey cerebrocortex buy discount hydrochlorothiazide 12.5mg on line. Afferent regulation of locus coeruleus neurons: Anatomy purchase hydrochlorothiazide 25mg without a prescription, physiology and pharmacology generic hydrochlorothiazide 25mg on line. Serotonin agonists cause paral- lel activation of the sympathoadrenomedullary system and the hypothalamo-pituitary-ad- renocortical axis in conscious rats 12.5 mg hydrochlorothiazide with visa. The effects of intrahypothalamic injec- tions of norepinephrine upon affective defense behavior in the cat generic 12.5 mg hydrochlorothiazide overnight delivery. The spino(trigemino)pontoamygdaloid pathway: Electro- physiological evidence for an involvement in pain processes. Ascending pathways in the spinal cord involved in the activation of subnucleus reticularis dorsalis neurons in the medulla of the rat. Analgesia induced by cold- water stress: Attenuation following hypophysectomy. The spinohypothalamic and spinotele- cephalic tracts: Direct nociceptive projections from the spinal cord to the hypothalamus and telencephalon. Physiological characterization of spinohypothalamic tract neurons in the lumbar enlargement of rats. Corticotropin-releasing factor pro- duces fear-enhancing and behavioral activating effects following infusion into the locus coeruleus. A functional neuroanatomy of anxiety and fear: Implications for the pathophysiology and treatment of anxiety disorders. Spinal and trigeminal lamina I input to the locus coeruleus anterogradely la- beled with Phaseolus vulgaris leucoagglutinin (PHA-L) in the cat and the monkey. Serotonin and the regulation of hypothalamic-pituitary-adrenal axis function. Differentiated cardiovascular afferent regulation of locus coeruleus neurons and sympathetic nerves. Locus coeruleus neurons and sympathetic nerves: Activation by cutaneous sensory afferents. Locus coeruleus neurons and sympathetic nerves: Activation by visceral afferents. Limbic pathways and hypothalamic neuro- transmitters mediating adrenocortical responses to neural stimuli. Nucleus locus ceruleus: New evidence of ana- tomical and physiological specificity. Evidence in experimental animals and humans, pathophysiological mechanisms, and potential clinical consequences. Responses of primate locus coeruleus neurons to simple and complex sensory stimuli. The neuropsychology of anxiety: An enquiry into the functions of the septo- hippocampal system. Systemic and specific autonomic reactions in pain: Efferent, afferent and endo- crine components. Responses of hypotha- lamic and thalamic neurons to noxious and scrotal thermal stimulation in rats. Characterization of pituitary me- diation of stress-induced antinociception in rats. Involvement of hypotha- lamic serotonin in activation of the sympathoadrenomedullary system and hypothalamo- pituitary-adrenocortical axis in male Wistar rats. Neuropeptide regulation of autonomic outflow at the sympathetic pre- ganglionic neuron: Anatomical and neurochemical specificity. Some psychiatric implications of physiological studies on frontotemporal portion of limbic system (visceral brain). Cytokines for psychologists: Implications of bidirectional im- mune-to-brain communication for understanding behavior, mood, and cognition. The neuropsychology and neuropharmacology of the dorsal ascending noradrenergic bundle—A review. Historical and modern concepts of hypothalamic organization and func- tion. Effects of physiological manipulations on locus coeruleus neuronal activity in freely moving cats. Aminergic and cholinergic afferents to the thalamus: Experimental data with reference to pain pathways.

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