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This concept is referred to gastritis stress generic pariet 20 mg with mastercard as genetically significant dose gastritis treatment and diet quality pariet 20mg, defined as the average annual gonadal dose to chronic gastritis diet plan purchase pariet 20mg without prescription the population of childbearing age, and estimated to be 20 mrem. An exceedingly important feature with significant impact on patient dose is appropriate collimation. An important part of radiation protection, then, is care and attention to detail to avoid technical errors requiring repeat images. Another component is a quality assurance program (through an ongoing preventive maintenance program and appropriate inservice education) that assures proper equipment function and compliance with established standards. Somatic effects are described as being early or late, depending on the length of time between irradiation and manifestation of effects. Early somatic effects are manifested within minutes, hours, days, or weeks of irradiation, and occur only following a very large dose of ionizing radiation. It must be emphasized that doses received from diagnostic radiologic procedures are not sufficient to produce these early effects. Occupationally exposed personnel are concerned with the late effects of radiation exposure. Some somatic effects like carcinogenesis have been mentioned earlier: the bone malignancies developed by the radium watch-dial painters as a result of radiation exposure to bone marrow, the thyroid cancers of the individuals irradiated as children for thymus enlargement, the leukemia eventually developed by patients whose pain from ankylosing spondylitis was relieved by irradiation, and the skin cancers developed by early radiology pioneers working so closely with the "unknown ray. Statistics revealed that radiologists, for example, had a shorter life span than physicians of other specialties. So much has been learned about the biologic effects of radiation since its discovery and a part of what we have learned has, sadly, been as a result of the experiences of the radiology pioneers. Fertility and heredity are greatly affected by the germ cells produced within the testes (spermatogonia) and ovaries (oogonia). Excessive radiation exposure to the gonads can cause temporary or permanent sterility, and/or genetic mutations. Spontaneous abortion, skeletal or neurologic anomalies (mental retardation and microcephaly), and leukemia are examples of embryologic or fetal somatic effects. With a large enough dose, in approximately 2 weeks, a moist desquamation can occur followed by a dry desquamation. Another skin response is epilation, that is, hair loss as a result of damage to hair follicles and associated structures. The most radiosensitive of these cells are the lymphocytes-cells involved in immune response. Sufficient exposure of the hematologic system to ionizing radiation can result in nausea, vomiting, diarrhea, decreased blood count, and infection. Exposure greater than 50 Gy or 5000 rad will affect the normally resilient central nervous system. Effects occur very quickly and include those mentioned above as well as ataxia and shock. Possible responses to irradiation in utero include spontaneous abortion, congenital anomalies, mental retardation, microcephaly, and leukemia or other childhood malignancies. Elective booking, patient questionnaire, and posting are suggested ways to avoid irradiation of a new embryo/fetus. Gonadal shielding is easier in the male patient because the reproductive organs are located externally. Genetic effects refer to damage to reproductive cells, affecting the reproductive capacity of the individual, or creating mutations that will be passed on to future generations. The genetic dose of radiation borne by each member of the reproductive population is called the genetically significant dose. Somatic effects include those manifesting themselves in the exposed individual and can be described as early or late effects. Early somatic effects can occur only after a very large single exposure of radiation to the whole body. Late somatic effects include carcinogenesis, cataractogenesis, embryologic effect, life span shortening, reproductive risks, and systemic effects. Occupationally exposed personnel are concerned with the late effects of radiation exposure. If you are able to answer the following group of very comprehensive questions, you should feel confident that you have really mastered this section. For greatest success, do not go to the multiple-choice questions without first completing the short-answer questions below. Identify the way in which all electromagnetic radiations are similar and in what respects they differ (p. Describe what is meant by the term ionizing radiation and how it differs from other electromagnetic radiations (p. Explain why occupationally exposed individuals are mainly concerned with the late, or long-term, effects of radiation exposure (p. Why is a W r assigned to different types of radiation; a W t assigned to different tissue types (p. With respect to the molecular effects of radiation, describe the difference between the direct and indirect effects; identify the one that occurs more frequently in the diagnostic range (p. Identify each of the following as either radiosensitive or radioresistant: muscle, nerve (fetal and adult), and epithelial tissue; lymphocytes; and reproductive cells (pp. How does each of the following affect the response of tissue to irradiation: tissue age, oxygen content, fractionation/protraction of radiation delivery (p. What can result from excessive radiation exposure during the second and third trimesters of pregnancy (p. Approximately how much fetal radiation do most diagnostic examinations deliver (p. List three methods the radiology department can use to avoid irradiating a newly fertilized ovum (p. Describe the effectiveness of gonadal shielding in the male versus female patient; discuss the importance of shielding children (p. Distinguish between early and late somatic effects; when does each occur with respect to initial exposure? If a quantity of radiation is delivered to a body over a long period of time, the effect: (A) will be greater than if it were delivered all at one time (B) will be less than if it were delivered all at one time (C) has no relation to how it is delivered in time (D) is solely dependent on the radiation quality 6. What is used to account for the relative radiosensitivity of various tissues and organs: 1. The beam of x-ray photons leaving the x-ray tube focus can be described as having what sort of nature?
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Husbandry There are two important considerations in establishing the living environments for these pets gastritis diet википедия cheap pariet 20 mg fast delivery. Assuring proper humidity and providing appropriate hiding places are essential to gastritis red wine generic 20 mg pariet visa maintaining healthy animals gastritis diet курс cheap 20mg pariet with visa. Scorpions evolved in tropical climates and as such have never escaped a biological dependance upon moist conditions. Caging should provide space for these animals to retreat from the heat as well as the sun. Scorpions fare well on a diet of soft-bodied grubs such as wax worms, moths, crickets, small spiders and mouse pups. Most captive animals will need to be offered fresh food on a weekly basis, however, the larger more active animals will need twice weekly feeding. Caution should be taken when handling the Hairy scorpions since their sting is painful. It is usually possible to herd the scorpions into a suitable carrier for transporting them short distances. Babies should be separated and fed wingless fruit flies, grubs or any other appropriate small insects. Medical Problems Scorpions are hardy animals and do not have many overt disease problems. The majority of the disease problems encountered center around improper husbandry practices as previously described. Likewise, as they get older they eat less and less food, eventually dying of old age. This usually occurs at night, and it is during this time that damaged limbs will be regenerated. Many spiders that are commonly referred to as tarantulas, and sold through pet stores as tarantulas, are actually members of a group of related spiders called Wolf spiders. Some of the common varieties available are the Bird-eating spider, Monkey spider, Pink-toed spider, and the Mexican red-leg spider. Tarantulas and the wolf spiders share many of the same characteristics and require similar care. Crickets, grasshoppers, meal worms and wax worms are readily available food supplies. Water can be supplied either in a shallow dish, or by misting the walls and foliage of the enclosure daily with a hand held spray bottle. Care should be taken not to allow the entire cage to get wet, or to allow the water to build up on one end which could cause the plants to rot and pathogenic bacteria to build up within the cage. The reason for this is that Tarantulas breath through specialized structures called spiracles (round openings on the underside of the abdomen). The most important consideration when handling tarantulas is to be aware that they are extremely fragile. A common misconception is that they are able to jump many feet from a standstill, and that they are extremely hardy. The hearts of spiders are located just a small distance from the underside of the body. If the animal is dropped the resulting concussion can cause severe damage to these delicate organs, and may be potentially fatal. Grasping the spiders by the section of the body to which the legs are attached will prevent the fingers from placing excessive pressure on the delicate internal organs of the abdomen. This will prevent them from struggling between your fingers, since spiders tend to remain motionless once they are removed from the surface. The second method, which is much less traumatic, is to coax the spider into one hand by gentle prodding from behind with the other hand. This method takes a little practice, and also takes a while to get used to if the handler is not accustomed to touching the spiders. With practice this gentle handling method should foster a better relationship between the pet and the owner. Although these creatures are not aggressive toward humans, there are some precautions which should be followed when they are handled. When disturbed or otherwise annoyed, tarantulas can flick hairs off of the dorsal part of their abdomens. These hairs can be hyperallergenic to some people, and can cause severe eye irritation and temporary blindness. The configuration and positioning of the tarantulas fangs are such that they must grasp their prey ventrally and inject their poison in a front to back direction. Therefore in order for them to inject venom into a surface as large as a human finger, the finger just about has to be placed directly under the mouth parts. Except for the rare allergic reaction to the venom, the tarantula bites from animals found in the continental United States are not poisonous to humans. Before purchasing any of these animals the buyer should be sure to identify the species. Reproduction It is possible to distinguish the sexes in the tarantula and wolf spiders. Both the male and the female tarantula reach sexual maturity during their seventh year. The mature male spider is identified by a sexual appendage called the ovigerous organ. During reproduction the organ is used for fertilizing eggs by depositing spermatazoa into the female. The male will usually die one to two months after their seventh year molt, regardless of how well they are cared for in captivity. The female deposits her fertilized eggs in a spherical web spun from her own silk. The spiderlets are highly cannibalistic and should be allowed to feed off each other for four to five days to thin out their numbers. After this time they should be separated and fed fruit flies or other suitable prey items. Medical Problems Other than the medical disorders previously discussed for invertebrates in general the tarantulas have very few problems. The most common is one brought about as a defense mechanism by the tarantula itself. When the animals is threatened or agitated it will exhibit a flicking of its body hairs at the eyes of its antagonist. They do this by rapidly brushing their rear-most set of legs over their back which projects their stiff, short dorsal body hairs in the direction of their predator.
- A thin flexible tube called a catheter is passed through the needle, into the artery, and up through the main vessels of the belly area until it is properly placed into a mesenteric artery. The doctor uses x-rays as a guide. The doctor can see live images of the area on a TV-like monitor.
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If the patient is unable to gastritis uti purchase pariet overnight maintain the position and the extremity falls away diet in gastritis order pariet 20 mg otc, the patient is considered to gastritis eating out buy pariet on line amex have a positive lag sign. Strength Assessment the relative strength of muscle groups can be assessed during the physical examination. Asymmetrical weakness on the involved side can provide additional diagnostic information. Weakness or paralysis of the scapular stabilizer muscles can be assessed by having the patient perform pushups against a wall. Neurologic Examination In the absence of trauma or brachial plexopathies, most neurologic lesions about the shoulder involve a peripheral nerve. Common peripheral neuropathies in the shoulder girdle include the suprascapular, spinal accessory, and long thoracic nerves. Although these conditions can be painful, many patients report dysfunction or cosmetic deformity as the presenting complaint. These lesions are appreciated during the inspection, range of motion, and strength testing of the shoulder girdle. Suprascapular neuropathy can occur at the level of the suprascapular notch or proximal and involve both the supra and infraspinatus tendons, resulting in prominence of the scapular spine and weakness of forward elevation and external rotation. Suprascapular nerve lesions at the level of the spinoglenoid notch involve only the infraspinatus muscle, resulting in atrophy of the infraspinatus fossa and weakness of external rotation. Spinal accessory nerve injury is often iatrogenic from a posterior cervical node biopsy or a radical neck dissection for malignancy. Long thoracic nerve injury is thought to be secondary to traction or contusion and affects the serratus anterior muscle, resulting in medial scapular winging. Medial or lateral refers to the direction toward which the inferior border of the scapula is directed. The majority of these nerve lesions (except iatrogenic laceration) recover without surgical intervention. Carroll Special Tests and Signs A variety of special tests or maneuvers have been described to evaluate individual structures or reveal specific pathology. The painful arc sign occurs when the patient experiences pain while elevating the upper extremity from 70 to 120 degrees. The Neer impingement sign is positive when shoulder pain is reproduced as the upper extremity is passively elevated in the scapular plane with the scapula stabilized. Impingement of the rotator cuff is demonstrated by passively elevating the shoulder against the fixed scapula. Pain suggests the possibility of mechanical compression of the rotator cuff against the anterior inferior acromion, a process known as impingement. The Shoulder 345 ment sign is tested by passively internally rotating the humerus when the arm is at 90 degrees of forward flexion with the elbow flexed. The drop-arm test is performed by placing the upper extremity at shoulder level (90 degrees) in the scapular plane with the thumb pointing downward. The test is considered positive when the patient is unable to maintain the extremity in this position and is indicative of superior rotator cuff pathology. The lift-off test is performed by having the patient place the hands behind the back with the arm internally rotated and the elbow flexed. The patient is then asked to lift the hands off the back without extending the elbows. If the patient is unable to perform the lift-off, the test is considered positive and indicative of subscapularis insufficiency. For patients who are unable to reach behind their back, the belly-press test can be used to evaluate the subscapularis. The belly-press test is performed by having the patient place the hands on the abdomen and, while pressing the hands to the abdomen, bringing the elbows anterior to the coronal plane of the body. The test is performed by having the patient maintain forward elevation of the upper extremity at shoulder height against resistance with the elbow extended and the forearm supinated. The test is considered positive when pain is produced in the area of the bicipital groove with this maneuver. The upper extremity is brought to shoulder height in forward flexion with the forearm fully pronated (thumb down) and adducted approximately 15 degrees. If this maneuver elicits pain in the shoulder, the test is repeated with the forearm supinated. If the pain is reduced or absent with the second maneuver, the test is considered positive. Shoulder Instability A number of tests have been described to evaluate shoulder instability. All the following tests can be performed with the patient is supine on the examining table. The apprehension test is performed with the shoulder abducted to 90 degrees and externally rotated to 90 degrees in the coronal plane of the body. If the patient experiences apprehension (fear of the shoulder dislocating), the test is considered positive. Carroll positive apprehension test, the examiner can reduce the subluxated humeral head by applying a posterior-directed force against the proximal humerus, thereby reducing the humeral head. If apprehension recurs with release of the posterior-directed force, the release test is positive. The load-and-shift test is used to assess the direction and degree of shoulder laxity. The examiner uses one hand to apply a longitudinal load to the humerus directed toward the glenohumeral joint. The other hand is used to apply a perpendicular force to the proximal humeral shaft in an attempt to shift (subluxate or dislocate) the humeral head relative to the glenoid. The test is performed while maintaining the upper extremity in the coronal plane of the body. The degree of abduction/rotation and the direction of the applied force can be varied to evaluate the various glenohumeral ligaments. The test is graded by the examiner who determines through tactile sense whether the humeral head translates to the glenoid rim (1+); over the glenoid rim but spontaneously reduces (2+); or over the rim requiring manual reduction (3+). Imaging Studies and Other Diagnostic Tests the use of routine imaging studies and tests to evaluate the shoulder girdle for diagnostic purposes is not recommended. At the conclusion of the history and physical examination, the examiner should have a reasonable diagnosis. If the clinical diagnosis is frozen shoulder but the examiner is concerned that the patient has glenohumeral arthritis, it is reasonable to order radiographs to rule out osteoarthritis because the natural history and treatment of osteoarthritis and adhesive capsulitis are dissimilar. If the clinical diagnosis is rotator cuff impingement or tendonitis, there is no reason to obtain further studies initially as they will not change the recommended course of treatment. Unfortunately, the axillary view is often not obtained, yet it is the most sensitive for documenting shoulder dislocations. The coronal and sagittal views are termed oblique because they are obtained in the plane of the scapula that is oblique to the coronal and sagittal planes of the body. Electrodiagnostic testing is useful in documenting both the presence and recovery of peripheral nerve lesions.
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For a fracture to gastritis diet электронное proven pariet 20mg be truly nondisplaced gastritis and coffee buy pariet overnight, no displacement of the radiographic landmark must be seen on at least two of the three radiographic views gastritis ultrasound order pariet 20 mg on-line. Incongruency-Besides fracture displacement, congruency of the femoral head within the acetabulum is analyzed. Subtle anterior subluxation can be seen on the obturator oblique view, and subtle posterior subluxation can be seen on the iliac oblique view (medialization of the femoral head with respect to the dome of the acetabulum). Minimally displaced fractures of the acetabulum can be diagnosed by detecting these subtle subluxations of the femoral head. Roof arc measurements-Roof arc measurements are defined as the angle formed by a line parallel to the patient passing through the center of the acetabulum and a line from the center of the acetabulum to the fractured area of the dome. These roof arc measurements are used for making decisions for surgery and are important in T-shaped and transverse fractures (see Treatment section). Computer systems that can remove the femoral head from the images are more useful for evaluation of the acetabulum. Occasionally, a gull sign is present where the displaced posterior wall remains hinged medially, with superior and posterior displacement of the lateral aspect of the posterior wall giving the appearance of a gull wing. The anterior roof arc begins at the posterior lip of the acetabulum, crosses the vertex and extends to the anteroinferior articular surface. The medial and posterior arcs begin at the mid and anterior lip of the acetabulum, cross the vertex, and extend to the acetabular fossa and posteroinferior articular surface, respectively. The fracture line exits the bone in the greater sciatic notch, traverses the articular surface, and usually exits through the obturator foramen and the inferior pubic ramus. Occasionally, the fracture line runs vertically, splitting the ischial tuberosity, without entering the obturator foramen. Depending on the size of the posterior column fragment, the fracture may involve part of the teardrop or brim of the pelvis anteriorly. The displaced posterior wall fracture remains hinged medially, with superior and posterior displacement of the lateral aspect of the posterior wall giving the appearance of a gull wing. The upper portion contains the roof of the acetabulum, and the lower portion contains a portion of the anterior and posterior wall and an intact obturator foramen (unless the obturator foramen is disrupted by an associated pelvic injury). Letournel subdivided transverse fractures based on where the fracture line traversed the acetabulum: (a) transtectal, the fracture line crosses the articular surface of the superior acetabulum; (b) juxtatectal, the fracture line crosses the junction of the articular surface and the superior cotyloid fossa; and (c) infratectal, the fracture line crosses through the cotyloid fossa. The transverse fracture line crosses both columns, but is not considered a both-column fracture. Transverse fractures have disruption of the anterior rim, posterior rim, iliopectineal line, and ilioischial line, but the obturator foramen is usually intact. Complex Fractures-Complex or associated fractures usually combine two of the simple fracture patterns. The vertical line usually disrupts the obturator foramen, which differentiates the T-shaped fracture from the transverse fracture. The vertical fracture line occasionally descends more posteriorly, splitting the ischium, keeping the obturator foramen intact. Furthermore, an anterior column fracture often involves the crest, which does not occur in T-shaped fractures. The both-column fracture also has separation of the two columns similar to that in T-shaped fractures and the associated anterior wall or column and posterior hemitransverse fractures. However, in the both-column fracture, the articular surface has been completely separated from the posterior portion of the intact innominate bone. All the other fracture patterns have some articular surface that remains in its original anatomic position attached to the intact portion of the posterior ilium. Because the two columns (with the entire articular surface) are displaced medially from the intact portion of the posterior ilium, a radiographic spur sign can be seen best on the obturator oblique view and represents the intact portion of the posterior ilium that remains in its anatomic position. Additional Fracture Patterns-In any classification system, there is some overlap in the fracture patterns. Furthermore, to reduce the number of fracture patterns to ten, some of the associated or kat. The spur sign represents the intact portion of the iliac wing that remains in its anatomic position. Closed reduction is not applicable for the treatment of displaced articular fractures of the acetabulum. In both-column fractures only, the articular surface is completely dissociated from the intact portion of the ilium. If the articular surface remains nondisplaced or minimally displaced and congruent around the femoral head, then secondary congruence exists, and nonoperative treatment can be considered. Relative contraindications to surgery include advanced age, associated medical conditions, and associated soft tissue and visceral injuries. Surgical Approaches-The choice of surgical approach depends on the fracture configuration. The Kocher-Langenbeck approach provides access to the posterior column, and the ilioinguinal approach provides access to the anterior column. Extended approaches (extended iliofemoral, triradiate, and simultaneous and sequential KocherLangenbeck and ilioinguinal approaches) are needed for some transtectal transverse fractures, T-shaped fractures, associated anterior wall or column and posterior hemitransverse fractures, and both-column fractures with significant displacement of both the anterior and posterior columns. Ideally, the surgeon chooses one approach that can be used to reduce and fix the entire fracture. The surgical approaches that are performed about the hip are listed in Table 16-3 with their dissection intervals, structures at risk, complications, and anatomic considerations. The superior gluteal nerve supplies the gluteus medius and minimus and the tensor fascia lata. The lateral femoral circumflex artery is deep to the rectus, lying in its sheath close to the femoral nerve. The lateral femoral circumflex artery has an ascending branch that lies within the psoas sheath. The superior gluteal nerve enters the muscles proximal to the incision Femoral nerve (retract or placed anterior to the rectus or too-vigorous retraction) Femoral artery and vein (retraction on top of the rectus vs. It sends muscular branches to the gracilis, adductor brevis, adductor longus, occasionally to the pectineus, and to the articular branch of the hip joint.
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Persistent symptoms sometimes respond to gastritis diet холодное order 20 mg pariet with mastercard bracing gastritis symptoms natural remedies order pariet 20 mg line, and treatment with a brace or cast is advocated by some when an acute pars fracture is suspected gastritis attack effective 20mg pariet. The majority of patients, both pediatric and adult, respond quite well to nonoperative treatment, although a return to high-level competitive sports is sometimes impossible. Operative treatment is recommended for patients with progressive spondylolisthesis, for skeletally immature patients with spondylolisthesis exceeding 50%, and for patients with persistent, incapacitating pain. Intertransverse fusion between the transverse processes of L5 in the sacral alae, utilizing iliac crest bone graft, has a high rate of success with a low complication rate. In adult patients with significant buttock and leg pain, or in individuals with neurologic deficits secondary to root compression, removal of the loose posterior arch of L5 and decompression of the exiting L5 nerve root are recommended. Many authors recommend pedicle screw instrumentation as an adjunct to spinal fusion; instrumentation is routine in adults, in patients with spondylolisthesis greater than 25%, and in individuals with documented instability. Finally, operative reduction of the spondylolisthesis is advocated by some in cases of severe spondylolisthesis, usually exceeding 60% to 70% slippage, with a concomitant cosmetic deformity. The results of surgery are usually quite rewarding, particularly in the pediatric population. Complications of surgery include failure of fusion, progressive slippage, persistent or recurrent pain, and neurologic injury. Lauerman adults, in higher grades of spondylolisthesis, and when reduction is attempted. Which of the following should not lead one to the diagnosis of battered child syndrome? Is characterized by the pelvis dropping on the contralateral side when weight is borne on the affected side d. All the following deformities typically cause problems simply because they do not remodel adequately, except: a. Klimkiewicz the emphasis presently placed on physical fitness in society in terms of overall health is at an all-time high. Participation in both organized and recreational sports has escalated during the past several decades as a result. This increase in participation has lead to an emphasis on treating injuries associated with sporting activities. A number of skilled physicians and other health professionals have developed interests regarding the specific care of athletes. The goal of sports medicine as a subspecialty is the prevention of injury, diagnosis and treatment of athletic injury, and returning athletes to preinjury activity with no acute or long-term sequelae. The purpose of this chapter is to focus on the biologic tissues involved in sporting injuries, highlighting the patterns in which they are injured. An overview then follows regarding the evaluation and treatment principles as they relate to the management of athletes and sport-specific injuries. Patterns of Injuries Injuries within the field of sports medicine can be generally classified into one of two categories: microtrauma and macrotrauma. Microtraumatic injuries are those that typically are associated with overuse injury by the athlete, such as many of the tendonopathies or stress fractures that are common in long-distance runners. Microtraumatic injuries are the result of repetitive stresses leading to structural breakdown of the tissue in question. Macrotrauma, on the other hand, involves a single traumatic episode resulting in injury to a specific region. A downhill skier fracturing the tibia, or a soccer player cutting and injuring the anterior cruciate ligament, are two examples of macrotraumatic injury. In these instances the force imparted to a specific tissue is greater than that tissue is able to withstand, resulting in catastrophic mechanical failure of that tissue. Klimkiewicz Musculoskeletal Tissues Tendons Tendons are strong, inextensible tissue that attach muscle to bone. They are composed of closely packed, well-aligned collagen bundles within a matrix of proteoglycan. Fibroblasts are the predominant cell type and are arranged in parallel orientation between the bundles of collagen fibers. The tendon fibroblasts act to produce both collagen and proteoglycan within the tendon unit. It is the high concentration of collagen in combination with its parallel orientation that gives tendons their high tensile strength. Collagen chains are linked together to form fibrils that in turn are bound together by a proteoglygan matrix to form a fascicle, the primary unit in tendon structure. Fascicles in turn are bound by the endotenon, a layer of elastin-containing loose connective tissue that supports the blood, lymphatic, and neural supply to the tendon unit. It is the endotenon that is contiguous with both the muscle fibers and periosteum at the musculotendinous and tendoosseous junctions, respectively. Acute tendon injuries may be direct, occurring as a result of laceration or contusion, or indirect, occurring secondary to tensile overload. In the majority of these cases, because most tendons can withstand tensile forces greater than can be exerted by their muscular or bony attachments, avulsion fractures and muscle tendon junction ruptures are far more common than midsubstance ruptures of tendon. Chronic tendon overload represents the classic microtraumatic injury in sports medicine. These injuries occur at the sites of high exposure to repetitive tensile overload. Whether inflammation has a role in the early stages of these overuse injuries is unclear. However, in cases that are not responsive to short periods of rest with persistence of symptoms, similar findings can be seen histologically, reflecting a more-degenerative process. Disruption of collagen fibrils, hyaline degeneration, and proliferation of vasculature are classic in these entities, termed angioplastic fibroplasias, and result in a tendonosis or breakdown of the corresponding tendinous unit. At this stage it is clear that this is not an inflammatory process, as no acute or chronic inflammatory infiltrates are demonstrable on these histologic specimens. Tendonosis is also observed in cases of spontaneous rupture and may be clinically silent until rupture occurs. An example is an Achilles tendon rupture seen in middle-aged athletes participating in strenuous sports. Site of injury Achilles tendon Iliotibial band Flexor hallicus longus tendon Patellar tendon Quadriceps tendon Supraspinatus tendon Extensor carpi radialis brevis tendon Flexor pronator origin Abductor pollicus longus tendon Extensor pollicus brevis tendon Running Dancing Basketball, volleyball Sport 259 Swimming, softball, baseball, golf, racquet sports Rowing Ligaments Ligaments are short bands of connective tissue that serve to connect two osseous structures. Similar to tendons, these are very organized hierarchical structures with high tensile strength. Ligaments are likewise composed of bundles of type I collagen fibers, which make up approximately 70% of its dry weight. Small amounts of elastin are combined with fibroblasts in a complex extracellular matrix. These fasiciculi can in turn be oriented in a simple longitudinal fashion, such as the medial collateral ligament of the knee, or can spiral to form a more-helical structure, such as the anterior and posterior cruciate ligaments of the knee. At their attachments to bone, the transition from ligament to bone occurs gradually in a series of distinct phases. These phases range from ligament to fibrocartilage, from fibrocartilage to mineralized fibrocartilage, and from mineralized fibrocartilage to bone.
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The stomach stores food and regulates its passage into the small intestine gastritis symptoms flatulence order generic pariet from india, where most digestion and absorption take place gastritis diet утуб purchase pariet 20 mg mastercard. The stomach chemically and mechanically digests food into the soupy mixture of uniformly small particles called chyme gastritis symptoms duration order 20mg pariet with visa. The stomach protects the body by destroying many of the bacteria and other pathogens that are swallowed with food or trapped in airway mucus. At the same time, the stomach must protect itself from being damaged by its own secretions. Before food even arrives, digestive activity in the stomach begins with the long vagal reflex of the cephalic phase (fig. Then, once food enters the stomach, stimuli in the gastric lumen initiate a series of short reflexes that constitute the gastric phase of digestion. In gastric phase reflexes, distension of the stomach and the presence of peptides or amino acids in the lumen activate endocrine cells and enteric neurons. Hormones, neurotransmitters, and paracrine molecules then influence motility and secretion. The Stomach Stores Food When food arrives from the esophagus, the stomach relaxes and expands to hold the increased volume. The upper half of the stomach remains relatively quiet, holding food until it is ready to be digested. Enhanced gastric motility during a meal is primarily under neural control and is stimulated by distension of the stomach. Gastric Secretions Protect and Digest the lumen of the stomach is lined with mucus-producing epithelium punctuated by the openings of gastric pits. The various secretions of gastric mucosa cells, their stimuli for release, and their functions are summarized in figure 21. In short reflexes, gastrin release is stimulated by the presence of amino acids and peptides in the stomach and by distension of the stomach. Coffee (even if decaffeinated) also stimulates gastrin release-one reason people with excess acid secretion syndromes are advised to avoid coffee. In cephalic reflexes, parasympathetic neurons from the vagus nerve stimulate G cells to release gastrin into the blood. It does this directly by acting on parietal cells and indirectly by stimulating histamine release. However, whenever we ingest more than we need from a nutritional standpoint, the stomach must regulate the rate at which food enters the small intestine. Without such regulation, the small intestine would not be able to digest and absorb the load presented to it, and significant amounts of unabsorbed chyme would pass into the large intestine. The epithelium of the large intestine is not designed for large-scale nutrient absorption, so most of the chyme would become feces, resulting in diarrhea. This "dumping syndrome" is one of the less pleasant side effects of surgery that removes portions of either the stomach or small intestine. While the upper stomach is quietly holding food, the lower stomach is busy with digestion. In the distal half of the stomach, a series of peristaltic waves pushes the food down toward the pylorus, mixing food with acid and digestive enzymes. Unfolding protein chains make the peptide bonds between amino acids more accessible to digestion by pepsin. The process begins when H+ from water inside the parietal cell is pumped into the stomach lumen by an fig. Cl- then follows the electrical gradient created by H+ by moving through open chloride channels. By learning the cellular mechanism of parietal cell acid secretion, scientists were able to develop a new class of drugs to treat oversecretion of gastric acid. The Stomach Balances Digestion and Defense Under normal conditions, the gastric mucosa protects itself from autodigestion by acid and enzymes with a mucus-bicarbonate barrier. Mucous cells on the luminal surface and in the neck of gastric glands secrete both substances. The mucus forms a physical barrier, and the bicarbonate creates a chemical buffer barrier underlying the mucus. Researchers using microelectrodes have shown that the bicarbonate layer just above the cell surface in the stomach has a pH that is close to 7, even when the pH in the lumen is highly acidic at pH 2. Mucus secretion is increased when the stomach is irritated, such as by the ingestion of aspirin (acetylsalicylic acid) or alcohol. In Zollinger-Ellison syndrome, patients secrete excessive levels of gastrin, usually from gastrin-secreting tumors in the pancreas. As a result, hyperacidity in the stomach overwhelms the normal protective mechanisms and causes a peptic ulcer. In peptic ulcers, acid and pepsin destroy the mucosa, creating holes that extend into the submucosa and muscularis of the stomach and duodenum. For many years the primary therapy for excess acid secretion, or dyspepsia, was the ingestion of antacids, agents that neutralize acid in the gastric lumen. But as molecular biologists discovered the mechanism for acid secretion by parietal cells, the potential for new therapies became obvious. It is particularly effective on collagen and therefore plays an important role in digesting meat. Pepsin is secreted as the inactive enzyme pepsinogen by chief cells in the gastric glands. Once in the stomach lumen, pepsinogen is cleaved to active pepsin by the action of H +, and protein digestion begins. Histamine diffuses to its target, the parietal cells, and stimulates acid secretion by combining with H2 receptors on parietal cells. H2 receptor antagonists (cimetidine and ranitidine, for example) that block histamine action are a second class of drugs used to treat acid hypersecretion. Intrinsic factor is a protein secreted by the same gastric parietal cells that secrete acid. It shuts down acid secretion directly and indirectly by decreasing gastrin and histamine secretion. Chyme entering the small intestine has undergone relatively little chemical digestion, so its entry must be controlled to avoid overwhelming the small intestine. Intestinal contents are slowly propelled forward by a combination of segmental and peristaltic contractions. These actions mix chyme with enzymes and they expose digested nutrients to the mucosal epithelium for absorption. Forward movement of chyme through the intestine must be slow enough to allow digestion and absorption to go to completion.
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Many possible combinationsandvariantsofthese"pure"injurypatterns can be seen clinically gastritis symptoms acute buy pariet american express. Fractures of the triquetrum-Fractures of the triquetrum most commonly occur as impaction fractures of the proximal pole gastritis from ibuprofen buy pariet 20mg on line. During forced dorsiflexion and ulnar deviation gastritis diet 5 meals 20mg pariet sale, the ulnar styloid may shear off a small fragment termed a chisel. Fractures of the capitate-Capitate fractures may occur in combination with scaphoid fractures (scaphocapitate syndrome) during extremedorsiflexionofthewrist. Hooks of hamate fractures are caused by a direct blow to the hand and are often seen in baseball players or golfers. The diagnosis may be missed initially and may lead to chronic symptoms and nonunion. Occasionally, these fractures may affect the flexor tendons to the ring or small finger causing tendinitis or tendon rupture. Fractures of the hamate body are often associated with dislocation of the fourth and fifth metacarpal bases. These injuries require open reduction and pinning of the fracture as well as the involved carpometacarpal joints. Fractures of the trapezium-Fractures of the trapezial ridge are analogous to hook of hamate fractures and are treated similarly (by excision) if they progress to nonunion. Theetiologyhasbeendebatedandmay include steroid use, microtrauma, or a connective tissue disorder. Because of the rarity of this condition, formal treatment guidelines are not available. In general, all conservative measures should be exhausted before aggressive bone grafting or scaphoid excision is contemplated. Treatment should be symptomatic unless degenerative changes progress and involve the midcarpal joint. Scaphocapitate arthrodesis or proximal pole excision has been recommended when nonoperative treatment fails. Predisposing factors include negative ulnar variance of the wrist and a one-vessel lunate vascular pattern. The lunate vascularity pattern has also been implicated with a one-vessel lunate (20% of the population) at a higher risk than a two-vessel lunate (80% of the population). The stages of the disease follow a predictable pattern of degeneration and aresummarizedinTable 23-1. When injury occurs, the delicate balance can be altered, resulting in loss of functionandinstability. Thesuccessfultreatment of carpal injuries requires an understanding of the intricate anatomy and kinematics of the wrist joint. Of the various concepts, the row theory has been most popular and best explains carpal dynamics. Theproximalrowincludesthe scaphoid, lunate, and triquetrum, each held together by intrinsic interosseous ligaments. Thedistalrowconsistsofthetrapezium,trapezoid, capitate, and hamate, also connected by intrinsic ligaments. The midcarpal joint is spanned by the extrinsic ligaments and accounts for 50% to 60% of total wrist motion. Some motion occurs within the proximal row, but the distal row bones are relatively fixed. The scaphoid functions as a link between the two rows, integrating motion and providing stability. The most important of the intrinsic ligaments are the scapholunate and lunotriquetral interosseous ligaments. Thescapholunateligament is stronger dorsally, and the lunotriquetral ligament is stronger volarly. These volar ligaments form a double V pattern (apex distal) with a weak area over the capitolunate joint known as the space of Poirier. The radioscapholunate ligament is mostly a mesentery of vessels and has little kat. Dorsally, the extrinsic ligaments converge on the triquetrum in a Z configuration (see. Kinematics-Carpal movements are complex and occur in three planes at both the radiocarpal and the midcarpal joints. A unique mechanism allows the proximal row to flex with radial deviation and extend with ulnar deviation. Thisnormallyoccursinasynchronous fashion but may be impaired in certain instability patterns (see later section). Specific patterns, however, are well known and can be used to guide treatment and predict outcomes. Thissystemexplains how lunate dislocation can occur as the result of a perilunate injury. Themostcommonof these injuries is the transcaphoid perilunate fracture-dislocation. Axial disruption patterns-Axial or longitudinal injuries have recently been classified according to their lines of cleavage through the carpus(Fig. Theserareinjuriesusually result from a blast or severe crush of the hand and wrist. Patterns of Instability-Instability patterns may develop after an injury (see previous section) or may be nontraumatic in etiology (such as in rheumatoid arthritis). Commonly, a carpal injury may occur and go unnoticed until it progresses to a more severe and symptomatic form of instability (such as a scapholunate ligament tear progressing to advanced collapse). For this reason, there is considerable overlap between acute injury and chronic posttraumatic instability. Because the lunate is separated from its scaphoid attachment, it rotates dorsally under the influence of the triquetrum (via the lunotriquetral ligament). Other findings include the "cortical ring" sign of the scaphoid and a triangular appearance of the lunate.
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Many disorders of immune system function can affect the formation of active immunity such as immunodeficiency (both acquired and congenital forms) and immunosuppression gastritis symptoms lap band purchase generic pariet from india. Artificially acquired active immunity Main articles: artificial induction of immunity and vaccination Artificially acquired active immunity can be induced by a vaccine gastritis diet 2 weeks purchase pariet us, a substance that contains antigen gastritis diet x1 order genuine pariet online. A vaccine stimulates a primary response against the antigen without causing symptoms of the disease. The term vaccination was coined by Richard Dunning, a colleague of Edward Jenner, and adapted by Louis Pasteur for his pioneering work in vaccination. The method Pasteur used entailed treating the infectious agents for those diseases so they lost the ability to cause serious disease. In 1807, the Bavarians became the first group to require that their military recruits be vaccinated against smallpox, as the spread of smallpox was linked to combat. Subsequently the practice of vaccination would increase with the spread of war There are four types of traditional vaccines: A. Inactivated vaccines are composed of micro-organisms that have been killed with chemicals and/or heat and are no longer infectious. Live, attenuated vaccines are composed of micro-organisms that have been cultivated un- der conditions which disable their ability to induce disease. Toxoids are inactivated toxic compounds from micro-organisms in cases where these (rather than the micro-organism itself) cause illness, used prior to an encounter with the toxin of the micro-organism. Most vaccines are given by hypodermic or intramuscular injection as they are not absorbed reliably through the gut. Live attenuated polio and some typhoid and cholera vaccines are given orally in order to produce immunity based in the bowel. An occasional drink is acceptable, but breastfeeding should be avoided for 2 hours after the drink. Mothers with untreated varicella should not feed from the breast, but in most cases pumped milk can be fed to the infant. Commonly Mistaken as contraindication are the following: Women who have cesarean deliveries: Initiate breastfeeding immediately, using a semirecumbent position on the side or sitting up. Women received vaccinations or live with vaccinated children: Neither inactivated nor live vaccines administered to a lactating woman or other family members affect the safety of breastfeeding for the mother or infant. Consult product prescribing information and the LactMed Database about specific drugs: If the surgical wound is painful, the other breast can be used but monitor infant growth because milk supply could be insufficient. Women who have hepatitis A: Initiate breastfeeding after infant receives immune serum globulin, and then vaccinate at 1 year of age. Women who have hepatitis B: Initiate breastfeeding after infant receives hepatitis B immune globulin and first dose of the 3-dose hepatitis B vaccine series. Women who have hepatitis C: Hepatitis C is not a contraindication for breastfeeding, but reconsider if nipples are cracked or bleeding. Women who have pierced nipples: Remove nipple accessories before feeding to avoid the risk of infant choking. Conservative surgical treatment: Excision, cauterization, or ablation of the lesions and lysis of adhesions. Meigs syndrome is defined as the triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor. Answer: A Uterine myomas (fibroid) are benign but can cause infertility or menorrhagia. Pressure: Pelvic pressure and bloating; constipation and rectal pres- sure; urinary frequency or retention. Pelvic symptoms: A firm, nontender, irregular enlarged ("lumpy- bumpy"), or cobblestone uterus may be seen. Answer: C if the presentation of this pt gush of fluid or leakage 96-what is papanicolaou smear? The transformation zone of the cervix is the region where squamous epithelium replaces glandular epithelium in a process called squamous metaplasia. Discharge covering the cervix may be removed carefully using a large swab, ensuring that the cervix is minimally traumatized. However, experts now know that it possible to have preeclampsia, yet never have protein in the urine. Tests that may be needed If your doctor suspects preeclampsia, you may need certain tests, including: Blood tests. These can determine how well your liver and kidneys are functioning and whether your blood has a normal number of platelets - the cells that help blood clot. A single urine sample that measures the ratio of protein to creatinine - a chemical That always present in the urine - may be used to make the diagnosis. Urine samples taken over 24 hours can quantify how much protein is being lost in the urine, an indication of the severity of preeclampsia. Your doctor may also recommend close monitoring of your baby growth, typically through ultrasound. The images of your baby created during the ultrasound exam allow your doctor to estimate fetal weight and the amount of fluid in the uterus (amniotic fluid). A nonstress test is a simple procedure that checks how your Baby heart rate reacts when your baby moves. Answer: A Signs and symptoms of Endometriosis: Cyclic pelvic pain, abnormal heavy bleeding and nodular uterus or adnexal masses. Order prolactin level Answer: B Women who breastfeed have a delay in resumption of ovulation postpartum. This is believed to be due to prolactin-induced inhibition of pulsatile gonadotropin-releasing hormone release from the hypothalamus. We recommend against the use of oral direct thrombin inhibitors (eg, dabigatran) or anti-Xa inhibitors (eg, rivaroxaban, apixaban) in pregnant women (Grade 1C). We suggest that anticoagulant therapy continue at least six weeks postpartum (Grade 2C). Environmental factors (eg, cigarette smoking) and immunologic influences also appear to play a role. Answer: I think A Cesarean delivery before the onset of labor may prevent microtransfusion that occurs with uterine contractions, and avoiding vaginal delivery eliminates exposure to virus in the cervicovaginal secretions and blood at time of delivery. Various nonthyroidal illnesses, medications, high estrogen states, and even prematurity can mimic hypothyroidism as a result of misleading laboratory findings. Do culture Answer: A In the first few days, the uterine discharge (lochia) appears red (lochia rubra), owing to the presence of erythrocytes. After 3 to 4 days, the lochia becomes paler (lochia serosa), and by the 10th day, it assumes a white or yellow-white color (lochia alba). Reference:4th year lecture 113)-The most accurate diagnostic investigation For ectopic pregnancy?
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No injury severity scoring system provides valid predictive data for when to gastritis duodenitis diet purchase pariet 20mg with amex amputate gastritis diet 5 meals buy discount pariet on line. The absence of plantar foot sensation on presentation is not predictive of function of the extremity or presence of foot sensation at 2 yr follow up diet untuk gastritis pariet 20 mg discount. Factors most associated with poor outcomes include older age, female gender, nonwhite race, lower level of education, current or previous smoking, living in a poor household, low self-efficacy, poor health status before the injury and involvement in the legal system for the purpose of obtaining disability. Patients who underwent below knee amputation including those with free flap coverage functioned better than above knee amputations. Thru knee amputations had the poorest functional outcomes and required the highest energy expenditure to ambulate. Patients treated with limb salvage have results comparable to patients treated with amputation. A free vascularized flap may also be necessary for proximal or middle-third defects if the soleus or gastrocnemius muscles are injured and inappropriate for transfer. Alternatively, distally based sural island pedicle flaps can be tunneled subcutaneously to provide full-thickness coverage of small or medium sized tissue defects of the distal leg without necessitating suture anastomosis of the vessel or significant donor site morbidity. Flap coverage should not be performed at the first debridement but in general should be performed within 1 week of injury. Antibiotics-Surgical treatment of closed tibial shaft fractures warrants antibiotic prophylaxis consisting of a first-generation cephalosporin administered intravenously before surgery and for 24 to 48 hours after surgery. Duration of postdebridement antibiotic prophylaxis is undergoing increased scrutiny, and recommendations range from 24 to 72 hours after debridement. The pre- and postoperative antibiotics are administered each time the patient undergoes operative debridement of the wound. Contaminated or dirty fractures-If the open fracture occurs on a farm or if it is contaminated with dirt, intravenous penicillin should be added for prophylaxis against anaerobes. A patient who has sustained an open fracture in a swamp or another large body of water should be treated with a third generation cephalosporin to minimize the risk of Aeromonas infection. This allows one to achieve a higher level of antibiotic (tobramycin or vancomycin) in the injured region than one could safely tolerate systemically (with intravenous antibiotics) and may lower the infection rate after openfracture. Both osteoconductive and osteoinductive agents are available to fill segmental defects. However, no product on the market has been shown to be superior to autogenous bone grafting. In another study that combined data from new patients with patients from a previous study, there was no demonstrated benefit when applied in conjunction with reamed nailing. Standard-Placement of external fixator halfpins should be performed perpendicular to the anteromedial surface of the tibia. The skin should be incised, and the subcutaneous tissues should be spread with a small clamp to avoid injury to the superficial structures, particularly the greater saphenous vein, which can be injured with placement of pins in the distal tibia. Predrilling the tract is strongly recommended before insertion of the external fixator pin. Stability-The stability of fixation achieved with an external fixator can be increased by allowing the fracture ends to contact (the most important factor), increasing the diameter of the half-pins (the next most important factor, since stiffness is proportional to the fourth power of diameter), decreasing the distance between the bar and the bone (the stiffness of each pin is inversely proportional to the third power of the bone-to-bar distance), increasing the distance between pins in each fragment of bone, and increasing the number of half-pins. Hybrid fixation-The use of a ring fixator allows the placement of pins and wires in the metaphyseal bone of the tibial plateau and plafond. Precise knowledge of the local crosssectional anatomy is necessary to prevent injury to the neurovascular structures. Healing-Assessment of fracture healing in a patient treated in an external fixator is oftenverydifficult. Oneclinicalsignoffracture healing is painless weightbearing on the affected extremity, but this sign can be misleading. When in doubt, it is safest to "dynamize" the external fixator, which will result in higher axial load with weightbearing, and thus may stimulate further healing. Alternatively, the fixator can be removed and the patient prohibited from bearing weight until further healing has occurred. Swelling of the leg increases for 2 or 3 days after the injury, so surgicaltimingisalsocritical. Occasionally,onemustwait7to10days,until the swelling and inflammation have subsided. Approach-The incision should be longitudinal and approximately 1 cm lateral to the spine of the tibia. In the event of significant swelling during surgery, this incision allows tension-free approximation of the medial dermis to the tibialis anterior muscle, thereby providing coverage of the plate, neurovascular structures, and bone. The plate can also be placed on the anteromedial surface of the tibia, but medial plates cause more symptoms after the fracture has healed and require kat. For distal extension, the incision crosses the anteromedial ankle and continues to curve posteromedially along the medial malleolus, allowing exposure of the tibial plafond and medial malleolus. The extensor tendons will be visualized, but the tenosynovium should not be violated and should be repaired with suture if they are injured. Otherwise,intheeventofawound breakdown, the tendons will be exposed to the environment and will be less resistant to bacterial contamination and infection. The majority of the lateral surface is straight, but its distal surface rotates anteriorly. Thus the plate may require a twist distally to match the tibial surface and to avoid the distal tibiofibular articulation. The medial surface is flared proximally and distally; if this is not taken into consideration with proper plate contouring, the tibia will be stabilized in valgus malalignment. At least six cortices of screw purchase are necessary on each side of the fracture to achieve stable fixation and permit early postoperative knee and ankle motion. Multifragmentary fractures, however, should not be treated with lag screws because the additional trauma to the osseous circulation far outweighs the benefit of the additional fixation. The plate is then secured proximally and distally, leaving the intervening fragments free and "loose" but with the best capacity to heal. Osteoporotic fractures benefit from the additional fixation strength afforded by the plate with locking screws, which function as a fixed angle device. Fractures with a zone of segmental comminution are effectively stabilized using a locked plate applied in a bridge fashion. Approach-Intramedullary nailing can be performed with the nail placed medial or lateral to the patella tendon, or through a patella tendon splitting incision. Placement of the nail with the patella tendon-splitting approach is straightforward and fairly easy, but one should avoid this temptation, since it could contribute to patella tendon symptoms. Whichever position for nail placement is chosen, the approach is through a midline or parapatellar incision.
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Arrest occurs when a bridge of bone ("bony bar") forms between the metaphysis and the epiphysis gastritis keeps coming back purchase pariet 20 mg with visa. The magnitude of the resultant deformity is determined by the remaining growth of the child as well as the location of the bar diet plan for gastritis sufferers purchase pariet mastercard. Partial physeal arrest is most commonly recognized on plain radiographs 3 to gastritis and duodenitis purchase genuine pariet 6 months after physeal injury. It may appear as a blurring and narrowing of the physis or as an area of reactive bone condensation. Common areas for growth arrest-The most common areas for growth arrest are the distal femur, distal tibia, proximal tibia, and distal radius. Interpositional material such as fat or Cranioplast may be used to prevent recurrence. Bar recurrence and incomplete resection have been shown to be factors contributing to poor results. Prevention of infection in the treatment of 1,025 open fractures of long bones: retrospective and prospective analyses. Growth disturbance lines after injury of the distal tibial physis: their significance in prognosis. The multi-institutional validation of the new screening index for physical child abuse. Seasonal variation in the incidence of wrist and forearm fractures, and its consequences. The most frequent traumatic orthopaedic injuries from a national pediatric inpatient population. Injuries when children reportedly fall from a bed or couch, Clin Orthop Relat Res. Early versus late femoral fracture stabilization in the multiply injured pediatric patient. Evaluation of initial base deficit as a prognosticator of outcome in the pediatric trauma population. Prediction of mortality in pediatric trauma patients: new injury severity score outperforms injury severity score in the severely injured. Introduction-Pediatric lower-extremity injuries occur much less frequently than upper extremity injuries. Long-bone fractures occur after high-energy trauma such as motor-vehicle accidents and sports injuries or after simple falls in younger children. Attention to detail when managing lower-extremity injuries can lessen the frequency of these undesirable outcomes. Because lower-extremity fractures can result from high-energy trauma, the patient must have a systematic evaluation. The primary survey is performed to exclude life-threatening injuries and is followed by the secondary survey. Management of specific musculoskeletal injuries depends largely on the age of the patient and the associated injuries. Open fractures are irrigated and meticulously debrided in the operating room before skeletal stabilization. Depending on the mechanical stability and extent of soft-tissue damage, some fractures can be managed in a cast that is windowed for wound care. External fixation, internal fixation, or traction is used for more extensive injuries. As with adult patients, surgical (skeletal) stabilization is generally preferred in cases of pediatric multiple trauma and in cases of head injury. Overview-Hip fractures, defined as injuries to the portion of the femur proximal to the lesser trochanter, are rare. The capital femoral epiphysis appears between 4 and 6 months of age, and the physis fuses between 14 and 16 years of age. The proximal femur contributes 13% of the length of the leg, or 3 to 4 mm per year. If the fracture is displaced, the leg may appear shortened and externally rotated. Type I-Type I fractures (transepiphyseal fractures [transphyseal separations]) occur more often in younger children. Treatment-Hip fractures, particularly displaced ones, require expeditious treatment. In general, in addition to internal fixation, all fractures require cast immobilization for at least 6 weeks if the child is younger than 10 years of age. Type I fractures-Type I fractures should undergo a gentle closed reduction and internal fixation. Fixation is achieved with smooth pins or with cannulated screws in older children. If the child is younger than 2 years of age, reduction and spica cast immobilization without internal fixation is a reasonable treatment for stable fractures. If unsuccessful, open reduction should be performed from the direction of the dislocation. If unsuccessful, an open reduction through an anterolateral approach should be performed. Although the physis should be avoided, stable fixation takes precedence over protecting the physis. Casts should be applied for 6 to 12 weeks for children who require immobilization. Achieving anatomic reduction requires that an anterolateral open reduction be performed if necessary. Reduction can be achieved under anesthesia or with traction and followed by the application of an abduction spica cast. If the fracture is irreducible or unstable in a cast, internal fixation should be used with a pediatric screw and side plate system. Coxa vara-The incidence of coxa vara after pediatric hip fractures ranges from 14% to 30% but is consistently lower and even absent in series using internal fixation. Observation for 2 years is acceptable because the deformity often remodels with time. Total involvement of the capital femoral epiphysis, physis, and metaphysis (Type I). A B C or lengthening may be performed if a large leg length discrepancy is anticipated.