By Z. Kadok. Pikeville College. 2018.

Since the contours are so clearly subsequent progression of the condition cheap epivir-hbv 150 mg free shipping. In an investigation of over 700 patients quality epivir-hbv 100 mg, the surface is symmetrical or asymmetrical epivir-hbv 100 mg with amex. However generic 150mg epivir-hbv fast delivery, the following factors of relevance to prognosis were resulting image is greatly dependent on the positioning determined: of the patient trusted epivir-hbv 100mg. Since it is difficult to assess the extent of any asymmetry using moiré curves, other methods for the three-dimen- No other factors, including for example the extent of sional calculation of the back surface have been devel- rotation, lordosis, family history, sex, etc. We ourselves have designed a technique in which positive correlation with progression. The bar chart in dots of light are projected onto the surface of the back and ⊡ Fig. We used In a recent study the progression velocity of scolio- this method for 15 years. A grid pattern notable with a growth velocity of >or=2 cm/year, at ages is projected onto the surface of the back and a virtual between 9 and 13 years, bone ages between 9 and 14 »plaster cast« calculated. In boys, scolioses appear to progress at a later lordoses can be evaluated very reliably by computer and stage than in girls, even taking into account the skeletal any subsequent changes over time documented. If a scoliosis of >20° persists be- yond infancy, progression is inevitable. Additional imaging methods Computer tomography Progression in adulthood CT is suitable for checking rotation and has been used in In scolioses with a Cobb angle of over 50° on completion a number of clinical studies. Consequences of scoliosis Thanks to investigations involving substantial numbers Magnetic resonance imaging (MRI) of patients and observation periods of up to 50 years we MRI is a non-invasive, but expensive, method that can now know a great deal about the consequences of sco- be used for identifying intraspinal problems (anoma- lioses [3, 102, 103]. MRI is indicated if neurological symp- untreated scolioses is moderate after 50 years. It is not the incidence of back pain is increased, this is rarely seri- suitable for monitoring the progress of a condition as ous [103]. In the lumbar area, the outwardly visible cosmetic impairment only starts to appear from a lumbar prominence angle of 15° (corresponding to a Cobb angle of approx. Asymmetry of the waist, how- ever, can have a more detrimental effect on the cosmetic 3 appearance. Risk of progression in relation to age and the initial angle The probability of back pain is increased in: of the scoliosis. The probability of back pain is only slightly or moderately increased in patients with thoracic scolioses [3, 103]. Paralysis Spontaneously occurring paralysis does not occur in id- iopathic scoliosis (paralysis only occurs in cases of con- genital kyphosis and secondary scoliosis resulting from a tumor). Although commonly used for many years it only provides an incomplete description of the possible types. This distinguishes 6 types of a b scoliosis, each of which can be subdivided according to the extent of lumbar deviation (⊡ Fig. Example of rapid progression of a scoliosis in a female sification is more reliable than that of King and is patient between the ages of (a) 11 years and (b) 17 years suitable for establishing the indication for modern surgi- cal procedures. Structural scolioses are defined by the measurement of a Reduction in life expectancy minimum scoliosis angle of 25° in lateral inclination on In serious cases (particularly thoracic scolioses, from ap- the functional x-ray. Contributory factors are as of the standing patient in order to determine the extent of follows: lumbar deviation. Treatment objectives ▬ Thoracic rigidity: thorax fixed in the expiration posi- ▬ Prevent progression tion. Exercises ▬ Brace treatment Cosmetic impairment Electrical stimulation An inconvenient rib hump, produced by rotation, occurs Operation particularly in C-shaped thoracic scolioses, and starts to 81 3 3. The vari- between 10° and 40°, »–« refers to a kyphosis of <10° and »1« a kypho- ous types (1–6, A–C) must be managed by differing surgical approach- sis of >40°. In the sagittal plane, the kyphotic angle is additionally measured cent scolioses, i. Even for this age group we only Whether physical therapy by itself can prevent the pro- record an x-ray if the clinical parameters suggest the oc- gression of the scoliosis or even improve the condition, currence of progression. The effect of exercises on the extent of the curvature has largely been rejected in the Plaster cast and brace treatment relevant English literature. Doctors in German-speak- Plaster cast and brace treatment is a non-surgical option ing countries are familiar with the treatment developed whose efficacy has been scientifically proven. A recently published con- In 1579, Ambroise Paré fitted 2 metal plates to the front trolled study showed, for the first time, that the scoliosis and back of the body to straighten a crooked spine.

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Diagnosis is important from the primary care standpoint and that appropriate 139 Enchondroma and enchondromatosis orthopedic referral is made for the above- mentioned clinical factors generic 150mg epivir-hbv overnight delivery. Enchondroma and enchondromatosis (Ollier’s disease) Solitary enchondroma and multiple enchondromatosis bear the same relationship to each other as do osteochondroma to osteochondromatosis order epivir-hbv 150 mg amex. Solitary enchondromas occur equally in males and females buy epivir-hbv 100 mg low cost, and are generally seen in the latter half of the first decade onward into adult life generic 150mg epivir-hbv with mastercard. The cartilaginous lesions lie within the substance of the medullary system of the limb bones cheap 100 mg epivir-hbv amex, with a high predilection for involvement of the phalanges (Figure 6. Anteroposterior radiograph of the hand demonstrating a large routine evaluation of a limb for other problems, enchondroma involving proximal phalanx fourth digit. Anteroposterior radiograph of the proximal humerus addition to the local signs of fracture the demonstrating enchondromatous involvement. Malignant transformation of a solitary enchondroma in the distal extremities is extremely rare, although somewhat higher in long tubular bones. The exact incidence of malignant transformation is unknown, although it is felt to be extremely uncommon. Appropriate identification by the primary care physician and orthopedic referral is indicated as some of these lesions will require curettage and bone grafting (more central axial lesions need periodic radiographic observation). Multiple enchondromatosis is a very rare condition in which there is a substantial proliferation of cartilage cells originating within the bone substance itself and also from the periosteum. The involvement may be of a single extremity, a portion of the extremity, or multiple extremities (Figure 6. In general, the long bones are shortened, bowed, and Miscellaneous disorders 140 broadened. Commonly, near the joints, the enlargements resemble large bulbous excrescences producing considerable cosmetic deformity. The association of multiple enchondromatosis and multiple hemangiomas has been termed Maffucci’s syndrome. Diagnosis is established by the clinical picture coupled with characteristic radiographs. There appears to be an increased incidence of malignant transformation in adult life with the exact incidence being unknown. Orthopedic management generally involves the treatment of limb length inequality, fracture care, and progressive follow-up of the lesions as to their malignant potential. Appropriate diagnosis and referral from the primary care standpoint is indicated. Unicameral bone cyst Unicameral bone cyst is a single cavity lined with a thin membrane and usually containing straw-colored fluid. It is slightly more common in males, and most commonly is seen in the upper end of the humeral metaphysis. Involvement of the femur and humerus accounts for well over three- quarters of all reported cases (Figure 6. Although there have been many hypotheses as to the etiology of these cysts, the most common currently accepted etiology is based on the theory of localized venous obstruction and subsequent intramedullary erosion. Generalized enchondromatosis (Ollier’s disease) with the physis, and presence of fluid (blood) under extensive involvement of the femur. It is recommended that patients with bone cysts be referred to the orthopedic surgeon for continuing management. Orthopedic treatment currently consists initially of fenestration of the lesion, infiltration with 141 Non-ossifying fibroma corticosteroids or other chemical compounds, incision, curettage and bone grafting for failures, and commonly simple periodic observation. The lesions tend to disappear eventually with skeletal maturity and are extremely uncommon in adulthood. Aneurysmal bone cyst An aneurysmal bone cyst is composed of vascular channels that contain blood or serosanguineous fluid. It is most commonly seen in the latter part of the first decade, and particularly in the early and mid-portions of the second decade. At least half of the cases have been reported in the long bones of the limbs, although the axial skeleton is not uncommonly involved, particularly the vertebra.

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Histopathologically it has been identified as an avascular necrosis of the metatarsal head generic epivir-hbv 100 mg free shipping. The condition presents as a painful metatarsalgia localized over the involved metatarsal head generic epivir-hbv 100 mg overnight delivery. Swelling is usually present and the pain is exacerbated by weight bearing and particularly by running and jumping buy generic epivir-hbv 150mg on-line. It is seen at the time of puberty and is Adolescence and puberty 112 more common in the female order epivir-hbv 150mg without a prescription, with well over three-quarters of all cases occurring in females order epivir-hbv 100mg with visa. 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. Initial treatment consists of warm soaks, local debridement usually with a cotton swab and an antiseptic solution, combined with loose fitting foot coverings, in concert with appropriate antibiotics when necessary. A number of surgical techniques are available and appropriate orthopedic referral should be obtained. The osteocartilaginous prominence seen in association with essentially a reactive calcaneal “pump bumps” and the presumed etiology. They are bony prominences protruding directly from the posterior–superior portion of the apophysis of the os calcis occurring under and directly adjacent to the Achilles tendon insertion. The term arose from the pain syndrome associated with the wear of high countered women’s fashion shoes (pumps) seen in years past. The constant “rubbing” from the counter produced a reactive change in the calcaneal apophysis resulting in what appeared to be an osteocartilaginous “lump. Radiographs fail to reveal any true bony lesion other than a bony prominence in the painful region. Localized erythema and edema (bursitis) usually accompany the localized tenderness. The natural history is benign in most cases, symptoms are often ameliorated by simply altering shoe wear. Occasionally soft in-shoe orthotics beneath the heel may shift the painful area away from the counter of the shoe. In less than 10 percent of cases that have been resistant to treatment, surgery may be necessary, consisting of resection of the bony prominence. Inasmuch as the results of surgery have not infrequently been disappointing, it is to be viewed as a last resort as the painful lump may be replaced by a painful scar. Adolescence and puberty 114 de Quervain’s disease de Quervain’s disease is an inflammatory tendinitis of the wrist affecting the extensor pollicis brevis and the abductor pollicis. The origins of the painful symptoms appear to be a by-product of an inflammatory process within the tendon sheath at the site where the tendons cross the wrist. The tendons run in a grooved bony tunnel that is often fairly narrow in dimension. Repetitive irritations of the tendons in this localized region may result in inflammation with swelling of the tendons and the peritendinous tissues, thereby providing little room within the tunnel for movement.

In a comprehensive evaluation buy discount epivir-hbv 100mg on-line, patients should be asked about their sleep—specifically purchase 100 mg epivir-hbv with mastercard, do they have any difficulty initiating or maintaining sleep? If the patient endorses any of these difficulties cheap epivir-hbv 100 mg line, psychologists can probe further and help determine whether there are (often easy) changes that can be made generic epivir-hbv 150mg fast delivery. For example purchase 150 mg epivir-hbv amex, does the patient discontinue caf- feine consumption eight hours and alcohol four hours before bedtime? ASSESSMENT OF CHRONIC PAIN SUFFERERS 221 What does the patient do when he or she wakes up in the middle of the sleep cycle? Patients should be asked about what treatments they have tried in the past and are using presently. Also, are they or health care providers considering addi- tional treatments in the future, such as surgery for their pain? If there is a pending treatment, what does the patient know about the procedure(s) be- ing considered, what are the patient’s expectations about the likely results, how confident are they in the potential of this treatment? How worried are they about the treatments being considered, what do their significant oth- ers think about the treatment(s) being contemplated? Answers to these questions are useful in evaluating whether patients have already assumed a self-management role or whether they see themselves as reliant on others for all their care. When patients with persistent pain seek compensation for lost wages or are involved in litigation, these processes can add an additional layer of distress. Keeping up with paper- work, phone calls, visits to physicians and hospitals, and meetings with attorneys are often undesirable activities. They may have realistic con- cerns about the potential outcomes of the assessment. Moreover, patients involved in litigation are usually in the awkward position of having to “prove” how disabled they are as a result of an injury. The more they at- tend to their limitations, the less they attend to their improvements. Yet an important part of rehabilitation is taking note of capabilities and maximiz- ing a “wellness” role. Psychologists should ask patients about these areas in order to assess whether compensation or litigation statuses might inad- vertently be contributing to and maintaining the patients’ symptoms. The psychologist needs to be vigilant for the potential of secondary gains color- ing the patient’s presentation. This cannot, however, be taken as an indication that those involved with litigation and receiving disability compensation are dissimulating or exaggerating. Moreover, although the studies suggest that litigation and compensation are predictors of dis- ability these factors are only relative predictors. That is, not every patient who is involved with litigation or who is receiving compensation will ipso facto respond poorly to treatment or report higher levels of pain (Turk, 1997). The clinician must be cautious not to overemphasize the role of 222 TURK, MONARCH, WILLIAMS these factors in his or her evaluation of chronic pain sufferers and in treat- ment recommendations. Patients’ Responses to Their Symptoms and Responses From Signifi- cant Others. When the patient experiences an increase in pain, does he or she complain about it to significant others? From a biopsychosocial perspective, antecedents and consequences of pain symptoms and associated behaviors can potentially shape future ex- periences and behaviors. Pain psychologists use this information to formu- late hypotheses about what behavioral factors in a person’s life may serve to maintain or exacerbate the pain experience. It is helpful to gather this in- formation through interviews with patients and significant others together as well as separately. During conjoint interviews the psychologist should observe interactions between the significant others and responses by sig- nificant others to patients expressions of pain and suffering. People who feel that they have a number of successful methods for coping with pain may suffer less than those who behave and feel helpless, hopeless, and demoralized. Thus, assessments should focus on identifying factors that exacerbate and ameliorate the pain experience. Is he or she so overwhelmed by pain and other stressors that he or she has little resources left to cope with his symptoms? If so, he or she may meet the criteria for a pain disorder associ- ated with both psychological factors and a general medical condition (if di- agnosed by a physician) in the Diagnostic and Statistical Manual (American Psychiatric Association, 1994). Does the patient have problems with pacing activities, so that he or she does more when the patient feels better, which leads to increased pain and subsequent sedentary behavior? The psychologist should not only focus on deficits and weakness in cop- ing efforts and coping repertoire but also strengths.

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