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Y. Masil. Marylhurst University.

The cysts are clearly benign and have a histologic constitution resembling that of a ganglion cyst buy female viagra 100mg on line. Baker described the lesions in 1887 buy female viagra 50 mg low price, giving rise to the eponym of Baker’s cyst female viagra 50 mg with amex. Differential diagnosis includes subcutaneous lipomas purchase female viagra 100 mg free shipping, popliteal aneurysms purchase female viagra 50mg otc, and benign and malignant tumors. All of these should be readily differentiated by radiographic texture, abnormal pulsation, computed tomography (CT) scanning or MRI if the cyst lies in an unusual location. After many years of surgical extirpation, with very frequent recurrences, sanity has begun to prevail, and recognition of the natural history of the disease is now being well appreciated. The vast majority of cysts will either recede in size or disappear within a two- to three-year period after clinical presentation or almost always by puberty. It is to be remembered that ganglions most commonly occur on the dorsal or volar aspects of the wrist and often communicate with the joint. In the absence of clinical symptoms, all cysts should be observed periodically and surgery should be avoided. Operations are generally reserved for those rare children who are suffering from significant pain and whose cysts persist until puberty. Anteroposterior radiograph of the thoracolumbar spine showing Spastic torticollis a thoracolumbar scoliosis. In addition to the far more common congenital muscular torticollis, there is a type of torticollis or “wryneck” that appears in the toddler to adolescent age group that is associated with either inflammatory conditions in the cervical region, traumatic lesions, tumors or neurogenic disorders. The obvious implication is that the source of the “wryneck” is secondary to some other medical condition apart from the sternocleidomastoid muscle. One of the more common reasons for a spastic torticollis is atlantoaxial rotary From toddler to adolescence 72 “subluxation. Typically the children “splint” and resist any attempts to rotate the head or the neck. The term rotary displacement is probably more appropriate inasmuch as it is uncommon to document any true radiographic subluxation of the atlantoaxial joint. Fortunately the condition resolves almost invariably and spontaneously, with or without treatment (physical therapy, traction, heat). Spastic torticollis is also occasionally seen following upper respiratory infections, in association with cervical adenitis. Presumably the inflamed lymph nodes irritate the sternocleidomastoid and the anterior cervical “strap” muscles, producing the torticollis. Diagnosis is established by identifying the primary infection and treatment by the primary care physician generally results in resolution of the torticollis. Spinal cord tumors and cerebellar tumors occasionally can produce a spastic torticollis. An adequate neurologic evaluation is mandatory and a part of evaluating all acquired cases of torticollis. Symptomatic treatment is generally used for spastic torticollis in the form of heat, massage, and intermittent cervical traction, providing there is no evidence of true cervical vertebral instability. Resolution is generally abrupt in inflammatory and atlantoaxial rotary displacements. Subluxation of the radialhead “Pulled elbow” is most commonly seen in children between one and five years of age. It occurs following an injury sustained in which the child’s forearm or hand is being held and the child attempts to fall away, or is lifted from 73 Muscular dystrophies the ground by the hands. The children tend to carry the forearm in a “lame” position of forearm pronation, and elbow flexion supported by the other hand (Figure 4. Supination of the forearm or pressure over the radial head increases the discomfort. True subluxation or dislocation of the radial head from its position against the capitellum has never been demonstrated radiographically or pathologically. The condition occurs when longitudinal traction is applied to the forearm with the arm extended and the forearm pronated. It is believed that a portion of the annular ligament becomes interposed between Figure 4. The characteristic location of a popliteal cyst between the radial head and capitellum and then semitendinosus and gastrocnemius muscles. The mechanism of production of subluxation of the radial head, and the forearm held in pronation.

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J Pediatr Orthop 17: 220–4 consequences discount female viagra 100mg on line, a knowledge of the malformation can oc- 5 purchase 50mg female viagra. Catonne Y buy female viagra 100mg online, Dubousset J order female viagra 100mg on line, Seringe R cheap female viagra 50 mg with mastercard, Conard JP, Dintimille H, Gottin casionally help in the differential diagnosis of the dis- M, Rouvillain JL (1992) Les coxa-vara infantiles. Desai SS, Johnson LO (1993) Long-term results of valgus oste- otomy for congenital coxa vara. In: Proximal femoral focal defi- J Bone Joint Surg (Am) 42: 1202–10 ciency: A congenital anomaly. Bohring A, Oppermann H (1997) A further case of vertical trans- Contrasts in gait mechanics of individuals with proximal femoral mission of proximal femoral focal deficiency? Am J Med Genet 71: focal deficiency: Syme amputation versus Van Nes rotational oste- 194–6 otomy. Ganger R, Grill F, Lehner A, Kotb H (1999) Kongenitaler Femur- tors leading to hip subluxation and dislocation in femoral lengthen- defekt. Hahn MP, Ostermann PAW, Richter D, Muhr G (1996) Pseudar- throsen im Kindesalter. Hamel J, Winkelmann W, Becker W (1999) A new modification of Changes in the functions of the hip with no structural rotationplasty in a patient with proximal femoral focal deficiency deformity and caused by spastic muscle activity. Jani M, Sponseller P, Gearhart J, Barrance P, Genda E, Chao E (2000) Internal rotation – Adduction The hip in adults with classic bladder exstrophy: a biomechanical analysis. J Pediatr Orthop 20: 296–301 Functional rotational deviations often exist in primarily 18. Acta Orthop Scand 21: 273 particularly during standing and walking when muscle 19. Kalamchi A, Cowell HR, Kim KI (1985) Congenital deficiency of the tone increases as a result of the upright body position femur. Khermosh O, Wientroub S (1991) Dysplasia epiphysealis capitis and the requirements for body control. J Bone Joint Surg (Br) 73: 621 seems to be of multifactorial origin: 21. Meyer J (1964) Dysplasia epiphysealis capitis femoris: a clinical- femoral anteversion ( Chapters 3. Acta Orthop Scand 34: 183–97 ▬ indirect effect of triceps surae activity (plantarflexion 22. Paley D (2001) Lengthening reconstruction surgery for congenital femoral deficiency. Pappas AM (1983) Congenital abnormalities of the femur and re- tion, flexion and adduction (unpublished data)) lated lower extremity malformations: classification and treatment. Pirani S, Beauchamp RD, Li D, Sawatzky B (1991) Soft tissue The internal rotation is accompanied by pronounced anatomy of proximal femoral focal deficiency. Patients with inadequate postural 563–70 strength are functionally unstable while standing and 26. Raimann A, de la Fuente M, Raimann A (1994) Dysplasia capi- press the knees together. Provided the internal rotation tis femoris und ihre Beziehung zur Hüftkopfnekrose (Morbus and adduction are not excessively pronounced, these pati- Perthes). Ribbing S (1937) Studien über hereditäre multiple Epiphysen- ents can derive some benefit from this posture as they störungen. Acta Radiol Suppl 34 are able to maintain a stable upright position without any 28. Rogala EJ, Wynne-Davies R, Littlejohn A, Gormley J (1974) Con- actual postural motor activity by lowering themselves and genital limb anomalies: frequency and aetiological factors. If the knees were in from the Edinburgh Register of the Newborn (1964–1968). Sabharwal S, Paley D, Bhave A, Herzenberg J (2000) Growth pat- However, the more capable of walking the patients are, terns after lengthening of congenitally short lower limbs in young the more this inward-turning position proves a hindrance children. J Pediatr Orthop 20: 137–45 as the knees rub together and catch on each other as the 30. Shim JS, Kim HT, Mubarak SJ, Wenger DR (1997) Genu valgum knee or foot swings forward.

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It is only natural that doctors should often have ▬ If patients and parents notice that you are giving their widely differing opinions order 50 mg female viagra free shipping, because they have had problem your complete attention buy discount female viagra 100mg, are not trying to widely differing personal experiences generic 50mg female viagra amex. One or two avoid the issue and are doing everything humanly poor experiences with a certain method or a certain possible to minimize the negative consequences cheap 50mg female viagra, they indication can substantially influence the thinking of are much more likely to accept the setbacks buy 50 mg female viagra otc, than if a doctor, despite the lack of any statistical basis. As they have the impression that you would rather steer the saying goes: »If two people share the same opinion, clear of the problem. Parents are often legal liability claims, but rather the fact that commu- astonished, therefore, to discover how many different nication with the treating doctor deteriorated after the opinions emerge, particularly if they visit four or five occurrence of the complication. You should not allow the previously con- ▬ The parents come to you for a second opinion: Parents sulted doctors to play off one against the other, nor are increasingly less likely these days to accept the should you feel proud if the parents talk negatively indication for surgical treatment just like that, and about other doctors while praising you yourself. Derogatory remarks Express your own opinion about the treatment in are completely inappropriate. If you frequently find accordance with your personal conviction, whether yourself being irritated by patients or parents and or not this differs from previous opinions. If my own think disparagingly of them, then pediatric ortho- opinion differs only slightly, I try to minimize the dif- paedics is probably not the right branch of medicine ferences, explaining to the parents that I share exactly for you. Any diversity of opinion will » You won’t understand children unless you yourself confuse the parents. While the reasons for the various have a childish heart, you won’t know how to treat opinions may be perfectly understandable, they con- them unless you love them, and you won’t love them tribute little to the successful outcome of an operation. If the parents have no objection, it is usually Medical history a good idea to let him know of the outcome, even if Whether you as a doctor will get along with a child will you hold a differing view. Since the visit to ▬ The parents would like to obtain a second (third, the doctor is arranged because of a problem experienced fourth…) opinion: This is a legitimate wish. You by the child, it is important that you talk to the child, should support the parents by promptly forwarding not primarily to the parents. For the pediatrician this the complete documentation relating to the case, if goes without saying. But orthopaedists who deal mainly possible, to the colleague in question. So it more difficult if the parents are unwilling to mention is almost a mortal sin to ask the parents first of all how the name of the doctor they intend to contact. As a rule, I only option in such cases is to hand over all the docu- always welcome the child first, after all the child is the mentation to the parents. Any siblings that attend will also want ▬ The parents would like to inspect, or take with them, to be welcomed. Bear in mind that everything you children in much more concrete terms than to adults: If The patient and the parents are entitled to view the records and make Children appreciate it when the doctor doesn’t talk down to them copies of them from on high... If you of the shoulders in reply and the child will look at the have managed to gain the child’s trust during your ques- mother inquiringly. You could ask the child whether it tioning, possibly by playing with it and, above all, if you hurts anywhere or ask it to point to where it hurts. Nor radiate calm and do not let yourself be rushed by pressure will you receive a useful answer to the next question: of time, you will be able to examine almost any child. But it is child something that would have much less direct impact perfectly possible to obtain such information from the on adults. Make specific suggestions about periods of time As a rule, I perform a full physical examination on that will be significant to the child, e. Adolescent girls may keep on their If pain is present it is always important to establish brassiere or an undershirt. It is important to respect the whether or not the pain is related to loading or move- privacy of children and adolescents. You can likewise discover this from the child itself to the office without their parents it is advantageous to if you ask very specific questions. But since most chil- have a third person present (nurse, secretary) during dren don’t visit your office because of pain they will be the examination. This will avoid raising any suspicion of unable to say exactly why they have come. A female person can help reassure the child »I’ve come to see you because of an intoeing gait! I might ask such children, for example, tant growth parameter it should never be forgotten. In this way the child problems, and you will often see children over a period comes to learn to trust you and feel as if it is being taken of years, if not decades. I always check the pelvic tilt and ex- always insist that the child should reply by rephrasing amine the back in the forward-bending test (I note the the question differently and asking the child again.

Types of fracture Epiphysiolyses of the distal fibula with/without metaphyseal wedge (Salter-I or II fracture): 3 50mg female viagra overnight delivery. Fibular epiphyseal separation and syndesmotic disrup- be carefully scanned on the 1st AP x-ray for such shell-shaped tears generic 100 mg female viagra free shipping. In isolation they can usu- ment is age-related: Below the age of 12 purchase female viagra 50 mg on line, we find periosteal best 50 mg female viagra, chondral ally be recognized on the lateral x-ray order female viagra 100mg otc, and occasionally on an AP x-ray, or bony avulsions with an intact ligament in around 80% of cases (c), by a metaphyseal wedge of varying size (b). They are often combined whereas intraligamentous ruptures are seen in around 80% of patients with shell-shaped syndesmotic disruptions. Consequently, whenever older than 12 years (d) a fibular epiphyseal separation is suspected, the fibular notch should 445 3 3. A stability test should not be performed during the first 6–8 weeks, since this is initially painful and does not Prognosis affect the treatment at all, and even impairs ligament heal- Pain: An os subfibulare can cause chronic pain in the vicin- ing during the first few weeks after the trauma. The pain per se or an additional instability are indications for surgical removal of the os- Imaging investigations sicle, possibly combined with a revision of the ligamentous AP and lateral x-ray to exclude bone lesions, particularly apparatus. Chronic signs of instability include repeated supination X-rays with the ankle held in a particular position are traumas, a feeling of insecurity, perimalleolar swelling, obsolete. Even if the ligament rupture has been treated appropriately, such signs can be Types of injury expected in around 10% of cases. Secondary symptoms The relationship between ligament strength and mechani- such as achillodynia or calcaneodynia, and pain or insuf- cal resistance of the bony attachment determines the in- ficiency of the posterior tibial tendon are common. Surgical treatment is indicated shell-shaped fragment suggests a fresh avulsion of the only after several months of unsuccessful proprioception attachment of the anterior fibulotalar ligament antero- training and muscle strengthening exercises for the lower medially on the lateral malleolus, which is subsequently leg and foot. Possible procedures, depending on the clini- rounded down and then no longer distinguishable from cal findings, are an anatomical ligament reconstruction a primary accessory ossicle. Like the hand, the foot Ligamentous lesions predominantly involve the an- is also exposed during play and sport. The fibu- forefoot are most frequently affected, as this is where localcaneal and posterior fibulotalar ligaments are less distortion, impact trauma and falling objects can lead to frequently affected. By contrast, only fairly substantial forces will lead to fractures in the rearfoot, hence their rarity during Treatment childhood. The treatment of an acute fibulotalar ligament lesion is principally conservative: plaster splint for 1 week to allevi- Diagnosis ate pain and reduce swelling. The findings on inspection Clinical features after removal of the cast will determine the subsequent The foot skeleton is generally very easy to palpate directly course of action. A substantial reduction in swelling and an in view of the thin soft tissue covering. Local tenderness absence of pain suggest that simple ankle distortion has oc- and swelling are strongly indicative signs of a fracture. On the other hand, distinct Imaging investigations swelling in combination with a hematoma suggest a liga- Most foot fractures can be clearly demarcated on standard ment rupture, which is treated functionally with approx. Additional views may month protection of the lateral ligament complex, e. In view of the increased risk of trauma exists about the indication for surgical correction of calca- recurrence, we additionally prescribe physical therapy with neal fractures, a CT scan can be worthwhile in visualizing additional proprioceptive and stabilizing training for pa- intra-articular steps. Often the apophyseal cartilage of the base of the 5th metatarsal or the accessory os vesalianum is confused with an avulsion fracture of the short peroneal tendon. The distinction is simple: The 3 physeal plate always runs longitudinally in contrast with the transverse fracture line. Furthermore, aseptic necrosis of the navicular bone and the 2nd metatarsal head (Köhler’s and Freiberg’s diseases respectively) or irregularities of the calcaneal apophysis can be confused with fractures or posttraumatic states. Growth plates are present at the proximal end of all a b phalanges and the 1st metatarsal, and additionally at the ⊡ Fig. Apophysis and fracture at the base of the 5th metatar- distal, subcapital end of the other metatarsals. Fractures always run in a transverse direction at this Fracture types point (b) Calcaneal fractures in children occur outside the joint in most cases, in contrast with the situation for adolescents and adults, where these fractures are predominantly intra- Treatment articular. Since there is usually a history of a fall from a Spontaneous corrections great height, the doctor must always look for additional While little is known about the remodeling capacity after injuries, particularly in the lumbar spine. Tilt deviations in the area of the occur in connection with snowboarding and must be metatarsals and phalanges, are corrected only in the main handled according to the principles for the management plane of movement, i.

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