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The lateral mal- leolus protrudes strongly and tends to perforate the skin order 40mg zocor visa. An external fixator can be used to reduce the rearfoot back underneath the tibia purchase zocor 20mg visa. The talus and tibia should then be transfixed with a medullary nail and the distal section of the tibia and fibula should be fused trusted zocor 40 mg. An MRI scan also provides evidence of The classification according to Leveuf is shown in the condition of the cruciate ligaments buy generic zocor 20 mg. Since this is not usually the A Danish study has calculated an incidence of 1 order zocor 10mg on-line. Etiology Treatment During pregnancy the knee remains in a hyperextended The treatment should start immediately after birth and position in some cases (approx effective zocor 40 mg. The lack of cruciate consists of intensive correction and stretching of the ligaments or fibrosis of the quadriceps can, in particular, quadriceps. Placing the infant in an appropriate position lead to dislocation of the knee. The hip is placed in 90° flexion aplasia of the cruciate ligaments is a triggering factor or a and the thigh supported down to the knee with a foam secondary phenomenon is not known. Most cases occur block; a weight is secured to the lower leg with bandages sporadically and are not hereditary. When the neutral position has been reached, corrective casts can Associated anomalies then be fitted in increasing flexion. This treatment is very Congenital dislocation of the knee can occur unilaterally successful during the first 3 months [16, 36]. By this stage, the quadri- with congenital hip dysplasia, clubfoot and other foot ceps can be surgically lengthened to permit flexion of anomalies. Naturally, the results of this treatment are Clinical features, diagnosis only moderate, whereas patients treated conserva- The dislocation of the knee is usually obvious at birth. An x-ray will confirm the diagnosis, and a lateral view will usually show increased inclination of the tibial plateau towards the back (⊡ Fig. The differential diagnosis must distinguish between a congenitally recurvated knee and subluxation or dis- location. While the knee is also (slightly or moderately) hyperextended in a recurvated knee, the joint surfaces of the femur and tibia are in regular opposition. If the knee is subluxated or dislocated, an ultrasound scan can confirm the presence of the cruciate ligaments at an early stage. The Frick tunnel view shows whether a fossa is present, providing reliable evidence of the presence of the cruciate ligaments. An even more reliable picture of the internal structures can be obtained ⊡ Table 3. In this case, an orthosis will > Definition be needed, ideally consisting of a »Heussner spring«, i. Congenital absence of – usually both – cruciate liga- an elastic support with metal lateral reinforcements and ments, often associated with congenital dislocation of a hinged joint. Even though experiments have shown that the knee, also occurs in connection with femoral hypo- such a support hardly has any effect on the sagittal forces plasia or a congenital proximal femoral deficiency and 3 (and only reduces valgus and varus rotation slightly), it fibular or tibial hypoplasia / aplasia. Greater stability (but also constituting more of Congenital cruciate ligament aplasia very rarely occurs in a handicap) is provided by the Lenox-Hill brace. Congenital cruciate lig- ing the anterior, and particularly the posterior, cruciate lig- ament aplasia is particularly observed in connection with aments is not possible while considerable growth potential congenital femoral hypoplasia, a proximal focal femoral remains and is also extremely difficult towards the end of deficiency, fibular deficiency and congenital dislocation growth, as the shape of the condyles is not normal. In tibial deficiency, by definition, the the knee undergoes a certain functional adaptation to the cruciate ligaments are absent.

If significant joint space narrowing is present on the 45° flexion PA radiograph purchase zocor 20mg, MRI is not indicated discount 20mg zocor free shipping. An and chondroitin sulfate potentially offer some relief MRI is valuable in assessing the status of the knee lig- in subjective symptoms purchase zocor 40 mg mastercard. Glucosamine is thought to aments and menisci buy 10mg zocor with mastercard, but generally tends to underesti- stimulate chondrocyte and synoviocyte activity generic zocor 40 mg online, and mate the degree of cartilage abnormalities seen at the chondroitin is thought to inhibit degradative enzymes time of arthroscopy (Khanna et al 40mg zocor overnight delivery, 2001). The role of and prevent fibrin thrombi formation in periarticular the bone scan remains controversial: isolated articular tissues (Gosh, 1992; Bucci, 1994; Muller-Fassbender surface defects that do not penetrate subchondral bone et al, 1994). Recent studies indicate that pain, joint may not be identified by bone scan. Arthroscopy con- line tenderness, range of motion, and walking speed tinues to remain the gold standard for the diagnosis of may be improved with these medications (Barclay, articular cartilage injuries. Tsourounis, and McGart, 1998; DaCamara and The Outerbridge classification system (Outerbridge, Dowless, 1998). However, there are no clinical data 1961) was initially developed for macroscopic grad- showing that these oral agents affect the formation of ing of chondromalacia patellae and has since been cartilage (Tomford, 2000). A recent modifica- with high-molecular weight hyaluronans remains an tion by the International Cartilage Repair Society option despite the lack of well-controlled studies (ICRS) (Brittberg, 2000; Brittberg and Peterson, demonstrating efficacy. Suggested indications for referral to an orthopedic surgeon with expertise in cartilage NONSURGICAL MANAGEMENT restoration techniques are presented in Table 9-5. Acute motion loss Gross deformity Traditional methods for treatment of chondral lesions Acute neurovascular deficit include the judicious use of nonsteroidal anti-inflam- Mechanical symptoms (catching, locking, sensation of a loose body) matory drugs combined with activity modification. Failed nonsurgical management greater than 3 months in duration Oral chondroprotective agents such as glucosamine Repeated giving way or complaints of instability 50 SECTION 1 GENERAL CONSIDERATIONS IN SPORTS MEDICINE SURGICAL MANAGEMENT quality and volume of repair tissue (fibrocartilage) is variable. These procedures are used in low demand patients with larger lesions (>2 cm2) or in higher Various surgical modalities exist for the treatment of demand patients with smaller lesions (<2 cm2). The goals are to reduce symptoms, and abrasion arthroplasty for several reasons: (1) it is improve joint congruence by restoring the articular sur- less destructive to the subchondral bone because it cre- face with the most normal tissue (i. Postoperative rehabilitation PALLIATIVE consists of nonweight bearing for 6 to 8 weeks and may include continuous passive motion (CPM) to improve Arthroscopic debridement and lavage is used to the extent and quality of the repair tissue. As MSTs are remove degenerative debris, cytokines, and proteases low-cost and relatively low-morbidity procedures, they that may contribute to cartilage breakdown. It is ide- remain the mainstay for the initial management of ally indicated in the patient with defect area less than small chondral lesions. Postoperative rehabilitation involves weight- bearing as tolerated and early strengthening exercises. RESTORATIVE In the absence of meniscal pathology, the results fol- lowing arthroscopic debridement are at best guarded. This restorative procedure results in the depth of chondrocyte death and cellular necrosis in hyaline-like cartilage which is believed to be superior the treated area and thus remains investigational. Postoperative reha- bilitation entails aggressive CPM and nonweight bear- ing for 6 weeks with a gradual increase to full-weight REPARATIVE bearing from 6 to 12 weeks. ACI is a costly procedure with a relatively lengthy recovery period and is most Marrow stimulating techniques (MST—microfracture, often used as a secondary procedure for the treatment abrasion arthroplasty, and subchondral drilling) involve of medium to larger focal chondral defects (>2 cm2). The resulting and articular cartilage which can be obtained from the TABLE 9-6 Surgical Management of Chondral Lesions PROCEDURE INDICATIONS OUTCOME Arthroscopic debridement Minimal symptoms, short-term relief Palliative and lavage Thermal chondroplasty Partial thickness defects, investigational Palliative (laser, radiofrequency energy) Marrow stimulating techniques Smaller lesions, persistent pain Reparative Autologous chondrocyte Small and large lesions with or without Restorative implantation subchondral bone loss Osteochondral autograft Smaller lesions, persistent pain Restorative Osteochondral allograft Larger lesions with subchondral bone loss Restorative CHAPTER 9 ARTICULAR CARTILAGE INJURY 51 TABLE 9-7 Results of Arthroscopic Debridement and Lavage AUTHOR N MEAN FOLLOW-UP RESULTS Owens et al, 2002 19 patients 24 months Fulkerson score 12 mos – 80. Osteochondral allograft can be used to treat larger ing the three-dimensional surface contour. Tissue matching and immunologic sup- using the patient’s own tissue; however, the lim- pression are unnecessary as the allograft tissue is ited amount of donor tissue confines this tech- avascular and alymphatic. The risk of tion consists of immediate CPM and nonweight donor-site morbidity increases as more tissue is bearing for 6 to 12 weeks. Postoperative rehabilitation includes often used as a secondary treatment option for early range of motion and nonweight bearing for 2 failed ACI in larger defects. It is most commonly indicated comes studies for arthroscopic debridement and for the primary treatment of smaller lesions con- lavage, microfracture, ACI, and osteochondral auto- sidered symptomatic and for similarly sized grafts and allografts.

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Eur Radiol Jan 30 (Epub ahead of tion of popliteal cysts in children with knee effusions cheap zocor 10 mg on-line. Seil R order 40 mg zocor with mastercard, Rupp S proven 10 mg zocor, Jochum P zocor 10mg otc, et al (1999) Prevalence of popliteal Roentgenol 180(2):395–399 cysts in children discount zocor 20mg free shipping. Siegel MJ (2001) Magnetic resonance imaging of mus- literature) Arch Orthop Trauma Surg 119(1–2):73–75 culoskeletal soft tissue masses discount 20 mg zocor with mastercard. Massari L, Faccini R, Lupi L, et al (1990) Diagnosis and 39(4):701–720 treatment of popliteal cysts. Saifuddin A, Burnett SJ, Mitchell R (1998) Pictorial review: 252 ultrasonography of primary bone tumours. Lang IM, Hughes DG, Williamson JB, et al (1997) MRI 53(4):239–246 appearance of popliteal cysts in childhood. Woertler K, Lindner N, Gosheger G, et al (2000) Osteochon- 27(2):130–132 droma: MR imaging of tumor-related complications. Fornage BD, Tassin GB (1991) Sonographic appearances of Radiol 10(5):832–840 superficial soft tissue lipomas. Rubens DJ, Fultz PJ, Gottlieb RH, et al (1997) Effective ultra- 220 sonographically guided intervention for diagnosis of mus- 17. Inampudi P, Jacobson JA, Fessell DP, et al (2004) Soft-tissue culoskeletal lesions. J Ultrasound Med 16(12):831–842 lipomas: accuracy of sonography in diagnosis with patho- 35. Radiology 233(3):763–767 graphically guided core needle biopsy of bone and soft 18. Miller GG, Yanchar NL, Magee JF, et al (1998) Lipoblastoma 16(5–6):458–461 and liposarcoma in children: an analysis of 9 cases and a 19. Giovagnorio F, Valentini C, Paonessa A (2003) High-reso- review of the literature. Can J Surg 41(6):455–458 lution and color doppler sonography in the evaluation of 37. Bramer JA, Gubler FM, Maas M, et al (2004) Colour Doppler 178(3):557–562 ultrasound predicts chemotherapy response, but not sur- 22. Laor T (2004) MR imaging of soft tissue tumors and tumor- vival in paediatric osteosarcoma. Torabi M, Aquino SL, Harisinghani MG (2004) Current Am Acad Dermatol 48(4):477–493; quiz 494–496 concepts in lymph node imaging. Alvarez-Mendoza A, Lourdes TS, Ridaura-Sanz C, et al 1518 Interventional Techniques 85 6 Interventional Techniques David Wilson CONTENTS stances are in suspected tumours of bone or soft tissue and when the nature and type of infection is 6. From the imaging the biopsy may be great advantages of limiting the extent of tissue planned. There should be form al consultation damage, reducing the need for anaesthesia and with the surgeon who would remove the lesion if shortening the stay in hospital. Whilst most of the it proves to be malignant and the pathologist who procedures listed are performed in adults using seda- will interpret the biopsy. Open biopsy will be pre- tion, it is common practice in children to perform a ferred when there is risk of sampling errors and light general anaesthetic or at least to administer a where the lesion is small and an excision for symp- heavy sedative. CT or US may be used to place needles next to a mass that is to be removed surgically. It is inevitable that soft tissue and bone biopsies will be required in children.

These panels provide a central area just over the patient with a high temperature (ideally 36 C) whereas in the rest of the room the environ- mental conditions purchase zocor 20mg free shipping, although still warm zocor 40 mg visa, are cool enough to allow reasonable com- fort for health personnel (Figs order 10 mg zocor amex. Head zocor 20 mg on-line, limbs trusted zocor 20mg, and genitalia are to be elevated order 20mg zocor with visa, and the patient should be positioned comfortably (see Chap. Stable FIGURE11 Thermal panels or heat radiators provide a central area of high temper- ature over the patient, allowing a lower temperature in the rest of the environment for staff and visitor comfort. Initial Management and Resuscitation 31 FIGURE12 Burn ICU beds should be spacious and should have independent ther- mostats to permit changes in room environmental conditions according to patient needs. Patients must be comfortable and pain free (see section below, Pain Control section), and patients and families should be trained in wound care and rehabilitation. A formal morning round should be established, with review of all systems and wounds when deemed necessary. We highly recommend performing an informal evening round to check the daily progress of the patient, and what corrections have been undertaken. At that time, it is useful to decide which patients need to have their wounds inspected the next morning. These multidisciplinary visits are completed with a biweekly multidisci- plinary meeting at which the discharge planning for patients is discussed in full. Barret Broomfield Hospital, Chelmsford, Essex, United Kingdom Advances in trauma and critical care have resulted in important improvements in burn management, improved survival, and reduced morbidity from major burns. Myriad physiological changes occur following thermal trauma, including fluid and electrolyte imbalances (systemic losses and shifts of water, sodium, albumin, and blood cells), metabolic disturbances (hypermetabolism, catabolism, and mal- nutrition), bacterial contamination of tissues and infection, complications in vital organs, and respiratory complication with or without the presence of inhalation injury. Emergency treatment focuses on stabilization of patients, treatment of asso- ciated injuries, fluid resuscitation, initial respiratory support, and emergency treat- ment of the burn wound. Soon after stabilization and resuscitation, a formal discharge plan (treatment plan, rehabilitation plan, and social support) is estab- lished. Focus of burn treatment is then shifted to the definitive burn wound treat- ment and to the general support of the patient, which include: Nutritional support General patient support Support of the hypermetabolic response Treatment of inhalation injury Pain management and psychosocial support 33 34 Barret Infection control and treatment of critical conditions Rehabilitation The general treatment of burn patients is outlined in the following sections. For more specific issues, such as rehabilitation, psychosocial support, and support of the hypermetabolic response, the reader is referred to the relevant chapters in this book. NUTRITIONAL SUPPORT The hypermetabolic response to burns is the greatest of any other trauma or infection. A major burn injury provokes a complex disruption of hormonal homeo- stasis that induces an increased resting metabolic rate and oxygen consumption, increased nitrogen loss, increased lipolysis, increased glucose flow, and loss of body mass. To meet postburn energy demands, all main metabolic pathways are utilized. Carbohydrate stores are small; therefore, carbohydrate intermediate metabolites, which are also essential for fat catabolism, are obtained from skeletal muscle breakdown, thus increasing muscle catabolism. Prolonged inflammation, pain or anxiety, environmental cooling, and sepsis can further exaggerate this postburn hypermetabolic response. One of the main principles underlying successful management of the post- burn hypermetabolic response is providing adequate nutritional support. In gen- eral, patients affected with more than 25% body surface area (BSA) burned and those patients with malnutrition or who cannot cope with their metabolic demands as a result of concomitant injuries or diseases should receive nutritional support. Total parenteral nutri- tion should be abandoned and reserved for patients who cannot tolerate the enteral route. Placement of nasoduode- nal or jejunal tubes is tedious and often not successful, and their advantages are dubious. They should be reserved for use in ventilated patients who are at risk for nosocomial pneumonia. When a nasoduodenal tube is used, it should be com- bined with a nasogastric tube. Ten percent of the enteral feeding is then infused via the nasogastric tube, and the rest via the nasoduodenal tube. In either tube- feeding regimen, the gastric residuals should be checked regularly.

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