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By W. Sobota. Bentley College. 2018.

The pain is predominantly triggered by the Pediatr Orthop 9: 551–6 ribs coming into contact with the iliac crest order 800 mg aciclovir free shipping. While children with very severe spastic cerebral palsies are unable to complain about the pain verbally buy generic aciclovir 400 mg line, this does not imply its absence buy generic aciclovir 200mg. However generic aciclovir 800mg mastercard, those who look after such patients generally notice when the children do experience pain buy aciclovir 200 mg with mastercard. Radiographic findings Compared to an idiopathic scoliosis, a neurogenic sco- liosis associated with cerebral palsy shows the following features: ▬ The scoliosis is in the form of a broad C-shaped arch: In patients with severely impaired balance and body control, the characteristic countercurves observed in a idiopathic scolioses are absent (⊡ Fig. This cor- relates directly with the patient’s mental and neurolog- ical status. This lack of countercurves is most marked in patients who are unable to either sit or stand independently, whereas cerebral palsy patients who are capable of walking always have a countercurve of varying degree on both sides of the main curve, al- though they are often unable to straighten themselves out as well as patients with idiopathic scolioses. Pelvic obliquity and hip dis- a location can mutually influence each other. The hip on the higher side of the pelvis is particularly at risk since it is adducted. There is no statistical correlation, however, between the side of the hip dislocation and the direction of the pelvic obliquity. Treatment ▬ In contrast with idiopathic scolioses, neurogenic sco- Therapeutic objectives lioses are frequently associated with a kyphosis. The Most patients are so severely disabled that they are con- kyphoses are usually thoracic and severe hyperlor- fined to a wheelchair. The seat of the wheelchair must dosis is often present at the lumbar level. In certain take into account the problems associated with the sitting patients the kyphosis is the dominating factor, over- position and the spinal deformity and be adapted accord- riding the lateral curvature in terms of severity. Stabilization of the trunk usually also improves the head control, in some cases giving the patient some head control for the first time. When the patient is upright, the unstable trunk tilts to one side as a result of weak muscle tone. Gravity pulls on the trunk, exacerbating 3 the deformity, which becomes increasingly fixed, par- ticularly during growth. Conservative treatment Brace treatment is possible provided the spine can be straightened sufficiently to allow the axial pressure to be deflected so that it is over the spine in the upright posi- tion. This goal can best be achieved if the plaster cast is prepared in a position of hypercorrection, because the patient will tend to spring back to his abnormal shape while wearing the brace. Brace treatment is indicated if the Cobb angle is between around 30° and 70°. No precise limit can be stated, since other factors unrelated to the severity of the scoliosis are also important, for example obesity, tolerability of the brace and the mate- rial, respiratory impediments, disorders of the airways and acceptance by the parents and caregivers. This allows flexion should not be fitted too tightly at the thorax because of movements yet still provides adequate lateral support the need to allow chest movements for breathing. If a brace is indicated it must be worn whenever the patient is in an upright position, because it replaces the postural function of the trunk muscles and must counter the de- transferring the pressure onto the skeleton as the spine forming force of gravity. If the scoliotic curvature is the collapses completely and the thorax comes to rest on the predominant factor and the kyphotic tendency is mini- pelvis. In our experience, the use of such a brace to sit up, and the increasing asymmetry means that the rarely produces pressure points. The head lies on a headrest, providing bet- When deciding on the indication, extension of stiffening ter head control. On the other hand, the patient’s gaze is and the surgical procedure, we must make a basic distinc- directed upwards, making contact with his environment tion between two situations for patients with a cerebral more difficult. Stabilization of the trunk also improves palsy: head control, enabling an upright position to be adopted. While these aids are accepted in cases of extremely abnormal postures, parents Since the mental faculties parallel, to some extent, the and caregivers tend to disapprove of them. A patient who brace at the apices when the trunk is in an upright posi- is able to walk requires the ability to rotate the trunk for tion (sitting or standing), regularly resulting in pressure this purpose. If the brace is widened at these points, the patient often increases to compensate for the stiff, spastic posture sinks further down, producing new pressure points or of the legs. The therapeutic objectives are accordingly very intervertebral disks are removed from the anterior side in wide-ranging. For patients who > The following objectives apply to patients who are able to are unable to walk, we tend to fix the instrumentation to walk: the pelvis and use the Luque-Galveston technique. In ▬ Correct the curvature (in order to improve balance), this method, a rod is first anchored in the pelvis in the ▬ Prevent progression, planned correct position, and the spine is then pulled ▬ Prevent decompensation.

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You don’t have to fully accept all suggestions but buy aciclovir 800mg visa, if you don’t effective 400mg aciclovir, you need to give reasons that will convince the editor that your opinion is reasonable generic 400 mg aciclovir amex. In doing this discount 200 mg aciclovir with visa, it is best to be pragmatic and not to be dismissive of the reviewers’ work generic 200 mg aciclovir fast delivery. Tabulating the responses makes it very clear what changes you have made and where you have made them. For comment 1, the reviewer’s suggestion has been met half way by shortening the section considerably but still leaving some information in the paper. For comments 2, 5, 6, 8, and 9, 127 Scientific Writing the reviewer’s suggestions have been accommodated entirely. For comment 3, the response is to politely point out that the explanation of the sampling processes was unclear in the original paper and has been amended. In response to the reviewer’s comment 4, it would be tempting to point out that Bland and Altman do not describe a “coefficient of repeatability” and that the reviewer might like to get his facts right! It is better to be certain that you have used the correct statistic and to just note what you have done, as in our reply. For comment 7, the decision has been left to the editor because the authors considered the figure to be essential to the message of the paper. Occasionally, you find that the reviewer has made disparaging or less than polite comments. Remember that two wrongs do not make a right and that responding with disparaging or impolite comments will not impress the editor. Occasionally reviewers may suggest that you include more work, seemingly forgetting that they are reviewing this paper and not the next one. This will take a prudent response, perhaps on advice from more senior researchers. Handling rejection As for disappointing them I should not so much mind; but I can’t abide to disappoint myself. Oliver Goldsmith (1728–1774) Letters of rejection may arrive much more quickly than letters of acceptance because some journals may reject up to 50% of papers before they are sent out for external review. If your paper is rejected without being sent out for review, you could expect to hear back from the journal within a month. If your paper falls into this category, it is probably considered to be insufficiently original, to be of minor interest to the journal’s readership, or to be scientifically flawed, too long, or incomprehensible. Editors strive to treat their external reviewers with respect and therefore do not send them papers that are perceived to be of poor quality. Whether or not your paper has been sent out for external review, the letter you receive will be very polite if the editor 130 Review and editorial processes decides to reject it. You will need to decide whether the paper needs some major attention or whether you misjudged the appropriateness of the journal. Once a paper is formally rejected, you are free to submit it to another journal either without changes or with a complete rewrite. We have now considered this very carefully at an editorial level and I am afraid that we have decided not to accept the paper for publication. I know that you addressed the comments made by the reviewers by making some modifications to the paper. However, our decision not to publish was on the basis that we did not feel that the information was new or would be of great interest to our readership. Thank you for your communication that you sent for publication in our correspondence column. With well over 2000 letters submitted every year, we sometimes have to make difficult editorial decisions. On the basis of the recommendations of the reviewers and the Editorial Office, it was not accepted. Both reviewers raised concerns regarding the study design, analysis, and interpretation of the data. We hope that you can use their comments to improve your manuscript for submission to another journal.

As a result order 800mg aciclovir overnight delivery, the fracture patterns seen are different to those seen in adults and aciclovir 800 mg low price, with the excep- tion of high-energy trauma incidents such as road traffic accidents buy discount aciclovir 200 mg online, childhood injuries tend to be of the limbs rather than the axial skeleton (Box 7 discount aciclovir 400 mg with amex. Instead buy aciclovir 400 mg, epiphyseal displacement results as the injury force is focused on the physeal region. Injuries around the physis are common in children as the physis is the main point of weakness in children’s long bones. The ligaments surrounding the joint are often stronger than the bone and, therefore, unlike the adult, a child is more likely to suffer fractures, including those into the physis, than ligamentous injuries and joint dislocations. To ensure that paediatric injuries are accurately diagnosed, a comprehensive system of radiographic assessment should be implemented and clues to assist in the recognition of trauma will be discussed within this chapter. However, it should be noted that, as with adults, occult trauma may not be identified on the initial radiographs and further imaging should be considered if the patient’s clinical symptoms fail to resolve within 7–10 days. Greenstick fracture: Bending and angulation forces tense the convex and compress the concave sides of the bone causing an incomplete transverse fracture on the convex side extending to the bone centre and a buckling deformity on the concave side. Torus fracture:A cortical deformity caused by compression and is usually metaphyseal in loca- tion. Lead pipe fracture: An incomplete transverse fracture of one cortex with an associated buckling of the opposite side. Plastic bowing fracture: Occurs as a result of deformation forces exceeding the elastic strain capability of the bone. Although an obvious fracture may not be generated, the bone appears bowed (bent) throughout its length. 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.

Patients with peri- For deep palpation to ascertain organ size order 200 mg aciclovir otc, the left tonitis lie still aciclovir 800 mg for sale, avoid the slightest motion order aciclovir 800 mg with amex, and may hand is placed over the right and steady pressure is draw up their legs to reduce intraabdominal pressure purchase aciclovir 800 mg line. First buy generic aciclovir 800 mg line, disease, lip/tongue telangiectasias from Osler– after the patient relaxes the abdominal muscles, the Weber–Rendu syndrome, or cushingoid facies. The physician then Abdomen: Increased intraabdominal pressure may asks the patient to contract the abdominal muscle by caused an everted umbilicus. Cachexia may be the placing his or her head to the chest; the physician pal- result of severe malnutrition or cancer. If tenderness is less during of the abdomen may result from obesity, gaseous abdominal contraction, then the process is intraab- distension, ascites, or organomegaly. If pain is Hernias: Valsalva maneuver may cause inguinal, felt after release of pressure, this “rebound” suggests umbilical, or femoral area hernias. Enlargement of AUSCULTATION edge of the liver most likely indicates cirrhosis, hepa- Supine: absence of bowel sounds in ileus secondary to titis, vascular congestion, or neoplasm. A pal- the small or large intestine, obstruction of the biliary pable spleen suggests congestion, tumor, or system, ureteral obstruction, or obstruction of the infection. Cultures for Chlamydia trachomatis and Neisseria gonorrhoeae METABOLIC DISORDERS AND TOXINS should be taken. PSYCHOLOGICAL DISORDERS Obturator test: The patient is placed supine with the hip flexed and knee joint bent. The hip is then rotated Anxiety, depression, hypochondriasis, somatoform internally and externally. Pain occurs if there is disorder, conversion disorder, and irritable bowel syn- inflammation adjacent to the obturator muscle. DIFFERENTIAL DIAGNOSIS DIAGNOSTIC STRATEGIES INTRAABDOMINAL DISEASE ACUTE ABDOMINAL PAIN Parietal peritoneal inflammation may be due to gener- This pain is a great challenge to the primary care physi- alized bacterial or chemical peritonitis, localized peri- cian, gastroenterologist, emergency room physician, 114 VI REGIONAL PAIN TABLE 22–1 I. Acute myocardial infarction, myocarditis, angina streptococcal, enteric bacillus) pectoris b. Esophageal rupture, esophageal spasm inflammatory disease, ruptured hepatic abscess) B. Diseases of the spinal cord (eg, tumor, tabes dorsalis, spinal ruptured ovarian cyst, rupture of follicle) cord compression) 2. Fracture or dislocation of the lower costal cartilages tension, stretching 5. Obstruction of small or large intestine (eg, tumor, adhesions, polymyositis hernia, volvulus, intussusception) III. Abdominal pain primarily of psychological origin ureteral obstruction) A. Rapid torsion of gallbladder, spleen, ovarian cyst, testicle, appendix 5. The history and physical History and physical examination are the foundation of the evaluation. Hemodynamically stable Figure 22–3 shows the initial algorithm for the evalu- No Yes ation of a patient who is hemodynamically unstable or has a rigid abdomen. These patients may need rapid No Suspect abdominal Rigid abdomen aortic aneurysm fluid resuscitation and immediate transfer to the oper- No Yes Yes ating room. Abdominal plain films/ Limited resuscitation/ Patients who are stable without a rigid abdomen are chest radiograph operating room best evaluated by localizing the signs and symptoms. First, whether the pain is well or poorly localized is Perforation Obstruction Nonspecific determined, as seen in Figure 22–4. Confirmed It is important to realize that women of childbearing Algorithm for the Treat age have many possible causes of abdominal pain. PEDIATRIC POPULATION Other possible causes of abdominal pain in the elderly Causes of acute abdominal pain in children are best include constipation, drug-induced pain from divided on the basis of age (see Figure 22–6). Most (75%) AAAs are asympto- It is important to determine the pattern of pain. All older patients with backache should have an chronic intermittent pain, chronic unrelenting pain abdominal exam to rule out AAA. Abdominal, flank, with an identifiable cause, and chronic intractable or back pain may indicate imminent rupture.

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