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Clinical Director, University of Illinois at Urbana-Champaign Carle Illinois College of Medicine
Traction on the femoral head is essen- anterior column is ?high on the greater sciatic tial in obtaining a reduction prehypertension spanish buy 50 mg atenolol with mastercard. Special clamps and the ball spike pusher to help with reduction in the acetabulum heart attack karaoke demi lovato 100 mg atenolol with visa. Note also the ball spike pusher blood pressure systolic diastolic buy 50mg atenolol overnight delivery, which is invaluable in reducing small fragments of the acetabular wall and for pushing on the iliac crest. A both-column acetabular fracture (a) was reduced and xed with a double-loop cerclage wire from the greater sciatic notch to a point just cephalad to the anterior inferior spine (b). The technique of insertion of the wires is as follows: c Both the medial and lateral aspects of the ilium are exposed to the greater sciatic notch. One exposure, usually the medial one, must be large; the opposite one may be small. The fracture must be reduced temporarily with clamps to safely pass the wire, in this case on a long, right-angled (Mixter) clamp. The approach in this case is the ilioinguinal one but modied to allow lateral exposure of the greater sciatic notch. The plates may be applied to the anterior column from the inner table of the Implants: Screws ilium to the symphysis pubis (Fig. Screws are essential, especially when fixing smaller frag- within the joint are a not uncommon cause of chon- ments. For fixation of the plate to the bone, fully threaded cancellous screws are desirable, the 6. These plates Kirschner wires, or cerclage wires, screw fixation can be molded in two planes and around the difficult of the fractures is essential. In large individuals, and in pelvic fixa- interfragmental lag screws, plates may be used to tion, the 4. In the acetabulum, where anatomic reduction of the intra-articular fragments is essential, the use of newer minimally invasive techniques is lim- ited. The posterior column in this area is extremely thin, and misdirected screws will commonly pen- etrate the hip joint. No screws should be placed in this area unless absolutely essential, and then only if directed away from the articular surface. Note that no screws are used in the central posterior portion of the acetabulum to avoid penetration of the articular surface. The most distally placed screw xes the plate to the ischial tuberosity, best seen in d. This will allow the sur- geon to carefully plan the position of the interfragmental screws and the neutraliza- tion plate along the posterior column (b). If the plate is not contoured properly, a fracture that appears reduced posteriorly may in fact be malreduced anteriorly (a). The postoperative care depends upon the ability of If there is concern about the quality of the bone, the surgeon to achieve stable internal fixation, which about gross comminution, especially of the medial in turn depends on the quality of the bone and the wall of the acetabulum, or about inadequate stability, adequacy of the reduction. In general, we maintain traction should be continued for 6 weeks until some skeletal traction and continuous passive motion healing of the fragments has occurred. If stability is deemed to be excellent, the Indocid (25 mg tid) is used to prevent heterotopic traction may be removed and the patient ambulated. Low-molecular-weight heparin or cou- Weight bearing is not started until some signs of madin is used in addition to prevent thromboem- union are present, usually by the sixth postoperative bolic disease. Avascular necrosis of the femoral head is a devas- Complications associated with acetabular fractures tating complication, developing in 6. It was only seen tions include thromboembolic disease, wound necro- in the posterior types in our series, and was 18% in sis, and sepsis. Avascular necrosis of the acetabular seg- nerve injuries, avascular necrosis, and chondrolysis, ments may also occur, causing collapse of the joint. Chondrolysis following acetabular fractures can occur with or without surgical intervention. In our first 102 cases, there were 22 sciatic nerve lesions, 16 post- At some centers (Mears 2003; Tile 2003) where con- traumatic and six postoperative. The technical difficulties by the spike of the anterior column or during sur- of securing good fixation of the acetabulum should gery using an ilioinguinal approach. We have seen not be underestimated; this also requires consider- one patient with a post-traumatic femoral artery able experience. A nerve cable graft was performed with as a bone graft and inserting an uncemented cup poor results, that is, no quadriceps function was with screws or a roof ring with screws and cement is restored.
The anterior approach is fracture lines within the joint can the adequacy usually the iliofemoral blood pressure 6030 order atenolol on line amex, the posterior prehypertension lower blood pressure order atenolol online pills, or the Kocher- of the reduction be confirmed (see Figs blood pressure medication potassium generic atenolol 50mg visa. This can be obtained by a approach is most commonly used in type B trans- corkscrew in the femoral neck to allow better verse or T fractures to control rotation, and is pre- retraction of the femoral head and visual- ferred by many surgeons because of the decreased ization of the articular surface (Fig. However, this preferably, a sharp hook over the greater remains a matter of debate, as the published results tuberosity can be used to give the same effect are still sparse (Ruedi et al. In order ? Holes should be drilled to accept the pointed to achieve an excellent reduction, the surgeon must forceps (Fig. In visualizing assistants are necessary for these operative proce- impacted fragments from either an anterior dures. Of even greater help than the number is the or posterior approach, it is important to move quality of the assistants, since the surgeon cannot the major fracture out of the way so that the continuously keep an eye on the vital structures, impacted fragment can be visualized. Essential instruments eral fragment is retracted like a book to allow include pointed fracture forceps, fracture reduc- reduction of the impacted fragment. Therefore, tion clamps, fracture pushers, and other standard work within the fracture where possible. Special pelvic reduc- ginally impacted fractures must be reduced in tion clamps are also available and are extremely this way. This notch and around the anterior inferior iliac spine clamp can be extremely helpful by applying direct may greatly facilitate derotation and reduction of forces to the fracture. Other techniques is situated in a vulnerable position in the greater include the use of cerclage wires (see Fig. The lateral cutaneous nerve of the thigh is commonly injured in iliofemoral or ilioinguinal approaches. Our knowledge of acetabular trauma has advanced Heterotopic ossification is a major postopera- considerably since the first edition of this book. Also, most large lateral extensile approaches of the hip which strip metropolitan areas in the developed world have the gluteus medius from the lateral iliac crest. Moed pelvic-acetabular referral centers with expert care and Maxey (1993), McLaren (1990), and others have available. The general orthopedic or trauma surgeon reported on the efficacy of Indocid, although this has needs to resuscitate the patient with acute trauma 13. In obese patients, the contralateral thigh gets in the way of the surgeons hand, and prevents correct placement of the guidewire. During placement of the anterior column guidewire, the femoral nerve, artery and vein are at risk. The sciatic nerve and all the structures that exit the greater sciatic notch are at risk. Hip exion relaxes the sciatic nerve, and draws it away from the starting point at the ischial tuberosity. The iliac oblique view is used to ensure that the guidewire remains posterior to the acetabulum and does not enter the greater sciatic notch. The surgeon must all joint trauma) reflects the damage to the articular ask the question: Can I fix the fracture, can anybody Straightforward fractures such as in a posterior wall Furthermore, avascular necrosis and other complica- or a posterior column fracture can be handled by tions may compromise the end result. Unfortunately, these surgeon who undertakes the operation must obtain simple fractures may be complicated by marginal an anatomical reduction and stable fixation for any impaction or comminution and may lead to poor chance of an improved result. If the fractures are comminuted and com- use all the described modalities to prevent the com- plex (type B or C), referral to an expert center is plications that occur frequently. Referral should be prompt Finally, the role of immediate total hip arthroplasty to allow early investigation and surgery to be per- is being clarified, especially for the older patient with formed, which will help with anatomical reduction. In older patients with a both-column more complex injuries, further courses and prefer- (Type C) fracture with secondary congruence, a more ably fellowship training are important. The prog- option if the patient develops late pain from avascu- nosis depends on the original injury, which (as in lar necrosis or osteoarthritis. This 65-year-old man sustained a fall while skiing and provoked a posterior wall fracture. During the acute total hip arthroplasty, a structural autograft of femoral head was used to restore the acetabular defect. Clin Orthop 151:81?106 mental screws and buttress plates is demonstrated in the Letournel E, Judet R (1981) Fractures of the acetabulum. J Orthop fractures without somatosensory evoked potential monitor- Trauma 8:127?133 ing. Clin Orthop 305:1112?123 Presented at the First International Symposium on the Sur- Geerts W, Jay R (2003) Pelvis trauma and venous thrombo- gical Treatment of Acetabular Fractures, Paris, France embolism.
Progressively intense pain in the low back or hip with radiation into the lower extremity blood pressure negative feedback loop cheap atenolol 50 mg online. The local Dull aching sacral pain accompanied by burning or pain is pressure-like or aching in quality blood pressure chart during exercise purchase cheapest atenolol and atenolol. Main Features Pain in a sacral distribution usually occurs in the fifth how quickly will blood pressure medication work buy on line atenolol, Associated Symptoms sixth, and seventh decades as a result of the spread of Typically, leg weakness and numbness occur three to bladder, gynecological, or colonic cancer. Sphincter distur- aching midline pain and usually burning or throbbing bance is uncommon. The Signs and Laboratory Findings rectal and perineal component of the pain may respond There may be tenderness in the region of the sciatic poorly to analgesic agents. Focal weakness and sensory Associated Symptoms loss with depressed deep tendon reflexes may be evi- With bilateral involvement, sphincter incontinence and dent. Signs and Laboratory Findings There may be tenderness over the sacrum and in the re- An intravenous pyelogram may show hydronephrosis. It may show a paralumbar or pelvic soft tissue ment of S1 and S2 roots will produce weakness of ankle mass and there may be bony erosion of the pelvic side plantar flexion, and the ankle jerks may be absent. Myelography may be positive if there is epidural is usually sensory loss in the perianal region and in the extension of disease. Usual Course Summary of Essential Features and Diagnostic the pain and sensory loss may be unilateral initially Criteria with progression to bilateral sacral involvement and Low back and hip pain radiating into the leg is followed sphincter disturbance. The physical findings Social and Physical Disability indicate that more than one nerve root is involved. Page 195 Summary of Essential Features Differential Diagnosis the essential features are dull aching sacral pain with the differential diagnosis includes post-traumatic neu- burning or throbbing perineal pain. There is usually sac- romas in patients with previous pelvic surgery, pelvic ral sensory loss and sphincter incontinence. Psychological causes may play an important part in (See also 1-16) protracted low back pain in a large number of patients. They will, however, rarely be seen to be the sole cause of Code the pain, nor will the diagnosis emphasize them in the first 533. X l a Definition Hypoesthesia and painful dysesthesia in the distribution of the lateral femoral cutaneous nerve. Main Features Prevalence: more common in middle age, males slightly System more often than females. Pain Quality: all complaints are Main Features of pain or related sensations in the upper anterolateral Constant pain in the groin and medial thigh; there may thigh region; patients may describe burning, tingling, be sensory loss in medial thigh and weakness in thigh aching, numbness, hypersensitivity to touch, or just adductor muscles. Associated Symptoms Signs If secondary to obturator hernia, pain is increased by an Hypoesthesia and paresthesia in upper anterolateral increase in intra-abdominal pressure. If secondary to thigh; occasionally tenderness over lateral femoral cuta- osteitis pubis, pain is increased by walking or hip mo- neous nerve as it passes through iliacus fascia under tions. Signs Hypoesthesia of medial thigh region, weakness and at- Relief rophy in adductor muscles. Diabetes or any Laboratory Findings other systemic disease will be treated appropriately. Surgical decompression of the lateral femoral cutaneous nerve as it passes under the inguinal ligament is, on rare Usual Course occasions, helpful in the patient who has failed conser- Constant aching pain that persists unless the cause is vative therapy. Essential Features Complications Hypoesthesia and paresthesia in upper anterolateral Progressive loss of sensory and motor functions in obtu- thigh. Differential Diagnosis Social and Physical Disability Radiculopathy of L2 or L3; upper lumbosacral plexus When severe, may impede ambulation and physical ac- lesion due to infection or tumor; entrapment of superior tivity involving hip. Page 198 Pathology Usual Course Obturator hernia; osteitis pubis, often secondary to lower Constant aching pain which persists unless cause is suc- urinary tract infection or surgery; lateral pelvic neoplasm cessfully treated. Complications Essential Features Progressive sensory and motor loss in femoral nerve or Pain in groin and medial thigh; with time the develop- its branches depending upon site of lesion. Social and Physical Disability Major gait disturbance if quadriceps femoris is paretic.
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- Sick sinus syndrome
- Severe injury
- Spinal tumor
- Blood clots, which may cause death if they travel to the lungs
- Rapid rises in altitude, SCUBA diving
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Symptoms: In Diagnostic Criteria some 30 to 40% of patients with endometriosis there are the history and the findings on clinical examination will no complaints except perhaps infertility blood pressure medication excessive sweating discount 100 mg atenolol fast delivery. When any doubt re- symptom of endometriosis is pain; it may manifest itself mains blood pressure normal level buy 100mg atenolol visa, a therapeutic trial with cyclic estroprogestogens as dysmenorrhea prehypertension at 19 atenolol 100 mg fast delivery, as premenstrual pain with menstrual will alleviate the pain in 8 of 10 cases. Lesions located in the inspection of the pelvic cavity has been used rather fre- pouch of Douglas may provoke firm adhesions between quently in recent years to verify the diagnosis and to the anterior wall of the rectum and the posterior vaginal evaluate the extent of the lesions. Acute pain episodes in wall; this location may cause pain on defecation during the right iliac fossa due to endometriosis may be mis- menstruation. Recurrent episodes of lower ab- fixed uterine retroversion due to endometriotic adhe- dominal pain, tenderness, and a slight fever may sions frequently cause deep dyspareunia. Endometriotic erroneously be taken for recurrent pelvic inflammatory foci that penetrate into or through the bladder wall may disease. Treatment Treatment of endometriosis will be hormonal or surgical Signs or combined. It will vary depending on age of the pa- On pelvic examination a fixed painful retroversion may tient, stage of the disease, and the main presenting prob- be found, or tender, enlarged, adherent adnexa on one or lem-pain or infertility or both. Small, tender nodular lesions, which are fre- consists of cyclic estroprogestogens or in the continuous quently palpated either in a sacro-uterine ligament or on daily administration of oral progestogens, for example, the posterior surface of the uterus, are almost pathogno- Lynestrenol or norethisterone acetate. During recent years excellent results have been obtained by the con- tinuous oral administration of Danazol, a strong antigo- Page 168 nadotropin and mild androgenic drug. In these circumstances treatment with broad will, depending on the indication and the stage of the spectrum antibiotics and local heat is indicated. If the disease, consist of conservative surgery preferably by pain disappears, this confirms the diagnosis. If the pain microsurgical techniques, or semiradical or radical sur- and the parametrial tenderness persist, another cause of gery, i. Definition Main Features Pain with low grade infection of parametrial tissues, Prevalence: genital tuberculosis has become quite un- especially the posterior parametrium. Synonyms: pelvic common in most developed countries thanks to the lymphangitis, chronic parametrial cellulitis. It re- mains a problem in many less developed countries System where pulmonary tuberculosis is still widely prevalent. Symptoms: the most frequent symptoms are sterility, pelvic pain, poor general condition, and menstrual dis- Main Features turbances. Genital tuberculosis presents under two Site: Lower abdomen, sometimes the back also. In the silent lence: Because histological proof of the diagnosis is forms there are no particular symptoms; there is no pain usually missing, the prevalence is unknown, but the and no fever. It may be found soon general symptoms and signs of the tuberculous process, after a delivery, especially if the cervix has been torn meno- or metrorrhagias, sometimes amenorrhea. In the active cases there is usually abdominal pain with or without low backache, and deep pyrexia, weight loss, and night sweats. The pain may occur during the premenstrual period and disappear dur- Signs ing menstruation, or it may be continuous, with premen- On pelvic examination a fixed retroversion with palpable strual exacerbation. Spontaneous pain and dysmenorrhea may be explained by a pyo- or hy- Signs drosalpinx or by a tuberculous pelvioperitonitis. A more or less severely torn cervix is found and either Dyspareunia may be due to a fixed retroversion or to an acute or a chronic cervicitis. Usual Course Pathology the tuberculous process may become latent or may heal Posterior parametritis on chronic cervicitis is believed to spontaneously. It may, on the other hand, evolve towards be due to extension of a cervical infection along the a pyosalpinx or an ovarian abscess or to a tuberculous lymphatics of the parametrium. Diagnostic Criteria Diagnostic Criteria and Treatment In advanced cases general symptoms and signs of the Diagnosis of cervicitis depends on finding agglutinated tuberculous process, abdominal pain or discomfort, signs leukocytes in the cervical mucus during the periovula- of a pelvic infection, together with a positive tuberculin tory period. The presence of an infected cervical canal test and bacteriological evidence of tuberculosis consti- and of a tender posterior parametrium and the absence of tute the basis of the diagnosis. Tubercle bacilli may be a history and of clinical findings suggestive of endome- cultured either from menstrual blood or from an endo- triosis make the diagnosis of posterior parametritis plau- metrial biopsy, taken preferably in the premenstrual Page 169 phase.