Julia M. Koehler, PharmD, FCCP

• Associate Dean for Clinical Education and External Affiliations
• Professor of Pharmacy Practice, College of Pharmacy and Health Sciences, Butler University
• Ambulatory Care Clinical Pharmacist, Transition Clinic and Pulmonary Rehabilitation, Indiana University Health, Indianapolis, Indiana

Displacement of the fat planes signifies soft-tissue swelling weight loss pills lip discount alli amex, but this could as well be due to a haematoma or soft-tissue infection weight loss pills really work generic alli 60mg with amex. By the second week there may be a faint extracortical outline due to periosteal new bone formation; this is the classic X-ray sign of early pyogenic osteomyelitis weight loss 10 000 steps buy generic alli 60 mg on line, but treatment should not be delayed while waiting for it to appear weight loss food delivery generic 60mg alli amex. An important late sign is the combination of regional osteoporosis with a localized segment of apparently increased density weight loss 7-day juice cleanse alli 60mg generic. Osteoporosis is a feature of metabolically active extreme weight loss buy alli cheap, and thus living, bone; the segment that fails to become osteoporotic is metabolically inactive and possibly dead. It is extremely sensitive, even in the early phase of bone infection, and it can therefore assist in differentiating between soft-tissue infection and osteomyelitis. Laboratory investigations the most certain way to confirm the clinical diagnosis is to aspirate pus or fluid from the metaphyseal subperiosteal abscess, the extraosseous soft tissues or an adjacent joint. Even if no pus is found, a smear of the aspirate is sent for detailed microbiological examination and tests for sensitivity to antibiotics. Immediate examination for cells and organisms through a simple Gram stain may help to identify the type of infection initially and assist with the early choice of antibiotic, but only until microbiological diagnosis through culture and antibiogram (the true etiological diagnosis to define specific treatment) is established. Aspiration will give a positive result in over 60% of cases that could be improved in case of open surgery by culture of tissue samples. In the very young and the very old, these tests are less reliable and may show values within the range of normal. This is a highly sensitive investigation, even in the very early stages, but it has relatively low specificity and other inflammatory lesions can show similar changes. In doubtful cases, scanning with 67Ga-citrate or 111In-labelled leucocytes has been considered, but its use is decreasing in favour of other modalities. Advantages of this modality include excellent differentiation between soft-tissue and bone infections, assessment of suspected infected sites with underlying structural bone alterations, and clear definition of infective foci within complex anatomical locations. There is widespread superficial redness, with a clear demarcation between infected and normal skin, and lymphangitis. Mild cases will respond to high dosage oral antibiotics; severe cases need intravenous antibiotic treatment. Acute suppurative arthritis Tenderness is diffuse, and movement at the joint is completely abolished by muscle spasm. In infants, the distinction between metaphyseal osteomyelitis and septic arthritis of the adjacent joint is somewhat theoretical, as both often coexist. Although the condition is rare, it should be kept well to the foreground in the differential diagnosis because it may rapidly spiral out of control towards muscle necrosis, septicaemia and death. Intense pain and board-like swelling of the limb in a patient with fever and a general feeling of illness are warning signs of a medical emergency. Acute rheumatism the pain is less severe and it tends to flit from one joint to another. Sickle-cell crisis the patient may present with features indistinguishable from those of acute osteomyelitis. In areas where Salmonella is endemic, it would be wise to treat such patients with suitable antibiotics until infection is definitely excluded. The diagnosis is made by finding other stigmata of the disease, especially enlargement of the spleen and liver. Staphylococcus aureus is the most common at all ages, but treatment should provide cover also for other bacteria that are likely to be encountered in each age group; a more appropriate drug which is also capable of good bone penetration can be substituted, if necessary, once the infecting organism is identified and its antibiotic sensitivity is known. Drugs of choice are flucloxacillin plus a third-generation cephalosporin such as cefotaxime. Alternatively, effective empirical treatment can be provided by a combination of flucloxacillin (for penicillin-resistant staphylococci), benzylpenicillin (for Group B streptococci) and gentamicin (for Gram-negative organisms). This is best provided by a combination of intravenous flucloxacillin and cefotaxime or cefuroxime. Fusidic acid is preferred to benzylpenicillin partly because of the high prevalence of penicillin-resistant staphylococci and because it is particularly well concentrated in bone. Treatment If osteomyelitis is suspected on clinical grounds, blood and fluid samples should be taken for laboratory investigation and then treatment started immediately without waiting for final confirmation of the diagnosis. The antibiotic of choice would be a combination of flucloxacillin and a second- or third-generation cephalosporin. Chloramphenicol, which is effective against Gram-positive, Gramnegative and anaerobic organisms, used to be the preferred antibiotic, though there were always worries about the rare complication of aplastic anaemia. The current antibiotic of choice is a third-generation cephalosporin or a fluoroquinolone such as ciprofloxacin. All patients with this type of background are therefore best treated empirically with a broad-spectrum antibiotic such as one of the third-generation cephalosporins or a fluoroquinolone preparation, depending on the results of sensitivity tests. However, if the clinical features do not improve within 36 hours of starting treatment, or even earlier, if there are signs of deep pus (swelling, oedema, fluctuation), and most certainly if pus is aspirated, the abscess should be drained by open surgery under general anaesthesia. If there is no obvious abscess, it is reasonable to drill a few holes into the bone in various directions. There is no evidence that widespread drilling has any advantage and it may do more harm than good; if there is an extensive intramedullary abscess, drainage can be better achieved by cutting a small window in the cortex. Once the signs of infection subside, movements are encouraged and the child is allowed to walk with the aid of crutches. At present, not more than one-third of patients with confirmed osteomyelitis are likely to need an operation and the percentage is decreasing; adults with vertebral infection seldom do. Simple skin traction may suffice and, if the hip is involved, this also helps to prevent dislocation. At other sites a plaster slab or half-cylinder may be used, but it should not obscure the affected area. Analgesics should be given at repeated intervals without waiting for the patient to ask for them. Septicaemia and fever can cause severe dehydration and it may be necessary to give fluid intravenously. Complications A lethal outcome from septicaemia is nowadays extremely rare; with antibiotics the child nearly always recovers and the bone may return to normal. But morbidity and sequelae are common, especially if treatment is delayed or the organism is insensitive to the chosen antibiotic. Epiphyseal damage and altered bone growth In neonates and infants whose epiphyses are still entirely cartilaginous, metaphyseal vessels penetrate the physis and may carry the infection into the epiphysis. If this happens, the physeal growth plate can be irrevocably damaged and the cartilaginous epiphysis may be destroyed, leading to arrest of growth and shortening of the bone. At the hip joint, the proximal end of the femur may be so badly damaged as to result in a pseudarthrosis. Suppurative arthritis this may occur: (1) in very young infants, in whom the growth plate is not an impenetrable barrier; (2) where the metaphysis is intracapsular, as in the upper femur; or (3) from metastatic infection. In infants, it is so common as almost to be taken for granted, especially with osteomyelitis of the femoral neck. Ultrasound will help to demonstrate an effusion, but the definitive diagnosis is obtained by joint aspiration. Secondary infection sites are easily missed when attention is focused on one particular area; it is important to be alert to this complication and to repeatedly examine the child all over. Pathological fracture Fracture is uncommon, but it may occur if treatment is delayed and the bone is weakened, either by erosion at the site of infection or by overzealous debridement. Chronic osteomyelitis Despite improved methods of diagnosis and treatment, acute osteomyelitis sometimes fails to resolve. Weeks or months after the onset of acute infection, a sequestrum may appear in the follow-up X-ray and the patient may develop a chronic infection and a draining sinus. This may be related to late or inadequate treatment but is also seen in debilitated patients and in those with compromised defence mechanisms. The cavity is lined by granulation tissue containing a mixture of acute and chronic inflammatory cells. Occasionally it appears in the epiphysis and, in adults, in one of the vertebral bodies. Clinical features the patient is usually a child or adolescent who has had pain near one of the larger joints for several weeks or even months. He or she may have a limp and often there is slight swelling, muscle wasting and local tenderness. Most often it is seen in the tibial or femoral metaphysis, but it may occur in the epiphysis or in one of the cuboidal bones. Metaphyseal lesions cause little or no periosteal reaction; diaphyseal lesions may be associated with periosteal new bone formation and marked cortical thickening. Its relative mildness is presumably due to the organism being less virulent or the patient more resistant (or both). Its skeletal distribution is more variable than in acute osteomyelitis, but the distal femur and the proximal and distal tibia are the frequent sites. If fluid is encountered, it should be sent for bacteriological culture; this is positive in about half the cases and the organism is almost invariably Staphylococcus aureus. Immobilization and antibiotics (flucloxacillin and fusidic acid) intravenously for 4 or 5 days and then orally for another 6 weeks usually result in healing, though this may take up to 12 months. If the diagnosis is in doubt, an open biopsy is needed and the lesion may be curetted at the same time. Curettage is also indicated if the X-ray shows that there is no healing after conservative treatment; this is always followed by a further course of antibiotics. X-ray appearances may be more difficult than usual to interpret because of bone fragmentation. Microbiological investigation If the wound is infected, a wound swab should be examined and cultured for organisms which can be tested for antibiotic sensitivity. Unfortunately, though, standard laboratory methods still yield negative results in about 20% of cases of overt infection. Routine wound swabs of open fracture wounds in the absence of infection is not recommended as cultured organisms are very unlikely to be the same as the organism causing any subsequent infection. Multiple tissue samples taken with clean, sterile instruments are preferred for microbiological investigations. The combination of tissue injury, vascular damage, oedema, haematoma, dead bone fragments and an open pathway to the atmosphere must invite bacterial invasion even if the wound is not contaminated with visible particulate dirt. Staphylococcus aureus is the usual pathogen, but other organisms such as Escherichia coli, Proteus mirabilis and Pseudomonas aeruginosa are sometimes involved. Occasionally, anaerobic organisms (clostridia, anaerobic streptococci or Bacteroides) appear in contaminated wounds. Treatment the essence of treatment of open fractures is prophylaxis of infection: thorough cleansing and debridement of open fractures, the provision of drainage by leaving the wound open, immobilization of the fracture and antibiotics. In most cases a combination of flucloxacillin and benzylpenicillin (or sodium fusidate), given 6-hourly for 48 hours, will suffice. If the wound is clearly contaminated, it is wise also to give metronidazole for 4 or 5 days to control both aerobic and anaerobic organisms. This is a viable treatment option and can lead to good results if the soft tissue and bone debridement is meticulous and complete and adequate vascularized and tension free soft tissue closure can be obtained; this may require advance soft tissue procedures such as local or free flaps. Clinical features the patient becomes feverish and develops pain and swelling over the fracture site; the wound is inflamed and there may be a seropurulent discharge. The presence of necrotic soft tissue and dead bone, together with a mixed bacterial flora, conspire against effective antibiotic control. Treatment requires soft tissue management and repeat debridement is required if there is evidence of inadequate debridement or infection. Traditionally it was recommended that stable implants (fixation plates and intramedullary nails) should be left in place until the fracture had united, and this advice is still respected in recognition of the adage that even worse than an infected fracture is an infected unstable fracture. However, advances in external fixation techniques have meant that almost all fractures can, if necessary, be securely fixed by that method, with the added advantage that the wound remains accessible for dressings and superficial debridement. If these measures fail, the management is essentially that of chronic osteomyelitis. The commonest of all predisposing factors is local trauma, such as an open fracture or a prolonged bone operation, especially if this involves the use of a foreign implant. Periprosthetic infection may evolve to chronic osteomyelitis and, due to its clinical relevance, will be addressed separately. In the worst cases a sizeable length of the diaphysis may be devitalized and encased in a thick involucrum. Sequestra act as substrates for bacterial adhesion in much the same way as foreign implants, ensuring the persistence of infection until they are removed or discharged through perforations in the involucrum and sinuses that drain to the skin. A sinus may seal off for weeks or even months, giving the appearance of healing, only to reopen (or appear somewhere else) when the tissue tension rises. Bone destruction, and the increasingly brittle sclerosis, sometimes results in a pathological fracture. The histological picture is one of chronic inflammatory cell infiltration around areas of acellular bone or microscopic sequestra. The usual organisms (and with time there is always a mixed infection) are Staphylococcus aureus, Escherichia coli, Streptococcus pyogenes, Proteus mirabilis and Pseudomonas aeruginosa; in the presence of foreign implants Staphylococcus epidermidis (frequently coagulase negative staphylococcus), which is normally non-pathogenic, is the commonest of all. The host defences are inevitably compromised by the presence of scar formation, dead and dying bone around the focus of infection, poor penetration of new blood vessels and non-collapsing cavities in which microbes can thrive.

Syndromes

• Allergic reactions to medicines
• Ataxia-telangiectasia
• Your child has reduced urine output, sunken eyes, sticky or dry mouth, or no tears when crying
• Diuretics
• Varicose veins are painful
• Trouble saying or understanding words
• Have recovered from an illness or condition and no longer have symptoms
• Cannot completely empty your bladder (urinary retention)

Many people report that no two days are the same hoodia gordonii 8500 mg weight loss 90 pills order genuine alli on line, the pain experience being variable and seemingly inexplicable weight loss group names generic alli 60mg line. Once pain has become chronic weight loss pills without exercise purchase alli 60mg with amex, amplification pathways can be activated locally and at both spinal and cortical levels weight loss exercise plan cheap 60mg alli with amex, leading to chronic and more widespread pain weight loss team names generic 60mg alli with visa, which is difficult to treat weight loss pills information cheap alli 60 mg otc, particularly if accompanied by mood changes. Anxiety and depression both affect the perception of pain and its response to interventions. Each of these is very common, and can have a big impact on individuals, and, as discussed below, may need management separately from any attempt to deal with joint damage or pain. Palpation may reveal bony swelling at the margin of the joint, signs of mild inflammation, such as heat over the joint line, and an effusion. On movement there is usually a reduced range, with pain at the end of the range, and crepitus may be felt as the joint is moved; in advanced disease instability may be detected. There are no nocioceptive receptors in the cartilage, which is the major tissue affected pathologically, but nocioceptive pathways do occur in subchondral bone, in periosteum and in the synovium and capsule of the joint. Hips Pain is usually felt in the groin, laterally over the hip and radiates down the anterolateral aspect of the thigh to the knee. Stiffness is usually experienced first thing in the morning and after having sat still for a while, but it quickly resolves on movement to be replaced by pain. Complex movements, such as getting in and out of a motorcar or putting on socks, which involve deep flexion combined with rotation, are often difficult or impossible to perform. Patients struggle with stairs and in the absence of a banister may only manage stairs on all fours. Examination reveals an antalgic gait, characterized by an uneven cadence, in which less time is spent in the stance phase of the painful limb. There is a globally reduced range of movement with internal rotation often restricted early in the disease progression. Patients sometimes report audible crepitus (crackling or grating sounds) coming from the knee as well as symptoms of instability (a feeling that the knee is going to give way). Fixed flexion deformity means that the knees cannot lock in full extension and thus patients cannot stand comfortably for prolonged periods due to muscle fatigue. Loss of flexion beyond 90 degrees makes standing from a sitting position difficult as patients cannot move their centre of gravity anterior to their mid-coronal plane. Examination reveals an antalgic gait, wasting of quadriceps muscles, joint effusion, joint deformity, and crepitus palpable and sometimes audible on movement. There is sometimes tenderness along the joint line and palpable osteophytes that can be tender. However, there are peculiarities to the phenotype of the condition at different sites. Clinical examination may help to differentiate between these different types of pain problem: areas of localized tenderness may reflect articular or periarticular pathology (but beware, referred tenderness can occur), and the presence of widespread pain or allodynia (severe skin sensitivity) may indicate pain sensitization. However, plain radiographs are so characteristic as to make other imaging studies unnecessary. The four cardinal signs are osteophyte formation, joint space narrowing, sclerosis of the underlying bone, and subchondral bone cysts. Again for research purposes it is important to try to understand whether the disease process is active or not, and what tissues are undergoing change. Interventions are generally divided into symptomatic therapies and disease-modifying therapies. As yet, there are no drugs with proven ability to modify the disease process, although claims have been made for many different agents. Disease modification can occur in response to mechanical interventions, such as joint distraction and osteotomy. Similarly, it is not easy to ascertain the severity of the functional problems that any individual patient may be experiencing. So the assessment of severity and of the likelihood of a good response to interventions such as surgery is difficult in routine clinical practice. One is largely reliant on what the patient says, supplemented by the observation of gait, any difficulties the patient has undressing, dressing or getting onto or off the examination couch and clinical examination. Self-management strategies include considering alterations of diet (particularly to lose weight), alteration in activities, changing footwear, taking a more positive approach to the condition and exercising more. These include the provision of information about the condition and its management, helping people to increase their exercise level and to do specific exercises to strengthen muscles around affected joints, footwear advice, and help with weight loss for those who are obese. More recent evidence has suggested that paracetamol is no better than placebo, but both have been demonstrated to reduce pain. Intra-articular local anaesthetic and corticosteroid injections can be considered as an adjunct to other treatments, but hyaluronan injections are not recommended because of lack of evidence. There are many different surgical options available, as discussed in more detail in other chapters in this book. Surgery is broadly divided into joint realignment, joint fusion, joint excision and joint replacement (arthroplasty), which may be total or partial (such as unicompartmental knee replacement). Surgery is usually confined to end-stage disease once pain has become refractory to other treatment options. However, a small but important minority of patients do not benefit from joint replacement (between 5 and 15%, lack of response being more common for knee replacement than hip replacement) and have persistent severe pain in the long-term post surgery despite no evidence of technical issues with the surgery performed. It is important to assess leg length and think about corrective footwear, and shock-absorbing shoes can help. Among the most useful interventions are the use of a stick in the contralateral hand to reduce loading while walking, and physiotherapy aimed at increasing the range of motion and improving muscle strength and pelvic stability. If pain becomes very severe, interfering with activities and sleep, then hip replacement is likely to be the best option. When these treatment modalities no longer control symptoms, total hip replacement is usually very effective. Keeping the quadriceps muscles strong is important, as they are key to knee stability. Corticosteroid injections can result in good pain relief for relatively short periods of time (a few weeks to months) and can, therefore, be of great value as an adjunct to a course of physical therapy, or to help a patient manage a planned, important life event such as a wedding. These include osteotomies of various types, and unicompartmental or total joint replacements. Arthroscopic joint lavage is not recommended because of insufficient evidence for efficacy over and above its very big placebo effect. Management therefore usually involves strategies that reduce pain without putting the patient at risk. In some instances the inflammatory or bony components are so great as to dominate the clinical and pathological features of the condition. There is very little osteophyte formation; the synovial fluid is usually bloody, and contains large numbers of apatite crystals, which may contribute to the damage. This shows the typical features of an atrophic form of osteoarthritis on the painful side. Those affected have symptoms of joint pain, polyarticular swelling and deformity from childhood. Adults have short stature and their radiographs reveal distorted epiphyses and tubular long bones. Neuropathic arthritis is a progressive, destructive form of joint disease associated with loss of sensation. The sensory loss leads to a relative lack of pain, but the joint damage is severe, and similar to that seen in atrophic arthritis (see above). Mseleni joint disease is an endemic form of osteoarthritis that affects the Tsonga people who live in Northern Zululand in South Africa. There appears to be a strong genetic component, with a prevalence of 5% of the population, but with women more often affected than men. The first phenotype has radiographic features with elements of multiple epiphyseal dysplasia and affects both genders from an earlier age; the second phenotype is a form of protrusio acetabulae occurring almost exclusively in women. It is occasionally due to a familial predisposition, or the existence of some metabolic disorder, such as hyperparathyroidism or hypophosphatasia, but it is usually sporadic and idiopathic. Attacks result in painful, hot swollen joints, and can be relieved by aspiration of the joint and injection of steroids, if not contraindicated, and the use of non-steroidal anti-inflammatory drugs. However, to what extent this is a distinct disease entity is still disputed, and there is no known treatment for the chondrocalcinosis. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis Incidence of symptomatic hand, hip and knee osteoarthritis among patients in a health maintenance organization. Whatever the cause, the condition, once established, may come to dominate the clinical picture, demanding attention in its own right. Aetiology and pathogenesis Certain sites are peculiarly susceptible to ischaemic necrosis including the femoral head, the femoral condyles, the head of the humerus, the capitulum and the proximal parts of the scaphoid and talus. The subchondral trabeculae are further compromised in that they are sustained largely by a system of endarterioles with limited collateral connections. Another factor which needs to be taken into account is that the vascular sinusoids which nourish the marrow and bone cells, unlike arterial capillaries, have no adventitial layer and their patency is determined by the volume and pressure of the surrounding marrow tissue, which itself is encased in unyielding bone. The system functions essentially as a closed compartment within which one element can expand only at the expense of the others. Any increase in fat cell volume will reduce capillary circulation and may result in bone ischaemia. Over 80% of cases are associated with high-dosage corticosteroid medication and/or alcohol abuse. These conditions give rise to hyperlipidaemia and fatty degeneration of the liver. Research has indicated that fat embolism plays a part, giving rise to capillary endothelial damage, platelet aggregation and thrombosis. It seems likely that coagulation abnormalities of one sort or another play at least a contributory role in some of the disorders associated with non-traumatic osteonecrosis. Extravascular marrow swelling High-dosage corticosteroid administration and alcohol overuse cause fat cell swelling in the marrow, a feature which is very obvious in bone specimens obtained during joint replacement. There is a rise in intraosseous pressure and contrast venography shows slowing of venous blood flow from the bone. This increase in marrow fat volume in the femoral head is thought to cause sinusoidal compression, venous stasis and retrograde ischaemia leading to trabecular bone death; in other words, the establishment of a compartment syndrome. Ischaemia, in the majority of cases, is due to a combination of several of these factors. In fractures and dislocations of the hip, the retinacular vessels supplying the femoral head are easily torn. If, in addition, there is damage to or thrombosis of the ligamentum teres, osteonecrosis is inevitable. Little wonder that displaced fractures of the femoral neck are complicated by osteonecrosis in over 20% of cases. Undisplaced fractures also sometimes result in subchondral necrosis; this may be due to thrombosis of intraosseous capillaries or sinusoidal occlusion due to marrow oedema. Other injuries which are prone to osteonecrosis are fractures of the scaphoid and talus. This is because the principal vessels enter the bones near their distal ends and take an intraosseous course from distal to proximal. Impact injuries and osteoarticular fractures at any of the convex articular surfaces behave in the same way and often develop localized ischaemic changes. During this time the most striking histological changes are seen in the marrow: loss of fat cell outlines, inflammatory cell infiltration, marrow oedema, the appearance of tissue histiocytes, and eventual replacement of necrotic marrow by undifferentiated mesenchymal tissue. A characteristic feature of ischaemic segmental necrosis is the tendency to bone repair, and within a few weeks one may see new blood vessels and osteoblastic proliferation at the interface between ischaemic and live bone. With time, structural failure begins to occur in the most heavily loaded part of the the mechanisms here are more complex and may involve several pathways to intravascular stasis or thrombosis, as well as extravascular swelling and capillary compression. Intravascular thrombosis Various mechanisms leading to capillary thrombosis have been demonstrated in patients with non-traumatic osteonecrosis. Usually this takes the form of a linear tangential fracture close to the articular surface, possibly due to shearing stress. However, until very late the articular cartilage retains its thickness and viability. The articular cartilage is obviously intact and the subchondral bone is well vascularized. The necrotic segment (B) has a texture similar to that of normal bone, but it may develop fine cracks. In the later stages the necrotic bone breaks up and finally the joint surface is destroyed. Local tenderness may be present and, if a superficial bone is affected, there may be some swelling. Imaging X-ray the early signs of ischaemia are confined to the bone marrow and cannot be detected by plain X-ray examination. X-ray changes, when they appear (seldom before 3 months after the onset of ischaemia), are due to (1) reactive new bone formation at the boundary of the ischaemic area, and (2) trabecular failure in the necrotic segment. Occasionally the necrotic portion separates from the parent bone as a discrete fragment. However, it is now recognized that in the case of the femoral head and the medial femoral condyle such necrotic fragments may have resulted from small osteoarticular fractures which only later failed to unite and lost their blood supply. This represents an undisplaced subarticular fracture in the early necrotic segment. At this stage the femoral head may still be spherical and (unlike osteoarthritis) the articular space is still well-defined.

Sometimes lethal complications (gas gangrene weight loss 60 day juice fast buy 60mg alli, septicaemia or malignancy) supervene weight loss pills that start with l order alli with visa. If the blister is likely to burst weight loss pills korea buy alli without a prescription, it is opened under aseptic conditions and dressed before applying the cast weight loss pills 20 pounds in 30 days generic alli 60mg. They remain unhealed because they are subjected to the repetitive trauma of walking weight loss pills xenadrine review cheap alli 60 mg on-line. A below-knee walking cast weight loss 7 days purchase alli without prescription, which eliminates the forefoot stage of the walking cycle, is applied and kept on for 6 weeks. Acute infected ulcers require bed rest, elevation of the foot, frequent wet dressings and local irrigation. Systemic antibiotics are used if there are symptoms and signs of general infection. Complicated ulcers are chronic ulcers associated with additional factors such as infection of deeper structures or deformity. The principles of management are ulcer debridement (which may have to be repeated many times) and protected weight-bearing; deformity correction and stabilizing operations (like arthrodesis) are performed, if needed, after sound healing has been obtained. Deep local excision is adequate as treatment and essential for histological confirmation. Recurrent plantar ulcers occur because the original causes (anaesthesia, muscle paralysis and walking) persist. Additional factors are: poor quality skin, excessive loading of the scar, deep-seated infection and poor blood supply. The risk can be minimized by constant vigilance and attention to hydration of the sole, the use of protective footwear, restricted walking and correction of stress-inducing deformities. Excessive pressures due to prominent metatarsal heads on the sole of the foot can be treated by: (a) plantar condylectomy and transfer of the long extensor tendons to the metatarsal necks; (b) dorsal displacement metatarsal osteotomies; or (c) excision of an entire ray in the foot. Intractable ulceration along the lateral border of the foot, due to equinovarus deformity, will need an appropriate triple arthrodesis or a more complicated joint-sparing procedure to render the foot plantigrade. Deformities of the calcaneum which produce high-pressure areas should be treated by re-establishing the posterior pillar of the arch of the foot, by doing an appropriately designed calcaneal osteotomy. Sometimes subtotal resection of the calcaneum is needed to get rid of persistent infection; after this type of surgery, the inside of the shoe heel will need to be padded. In the early stages the patient may have mild pain during walking and on examination there is local swelling, warmth and tenderness. Once the infection is controlled, the foot is immobilized in a below-knee cast; the involved bones fuse together and a stable, rigid foot results. Amputations (a) (b) Occasionally amputation is necessary to keep the patient ambulatory. However, this step should not be taken without careful consideration; amputation merely shifts the problem to a more proximal level where it will be even more difficult to manage because the stump is often insensitive in these patients. Moreover, facilities for prostheses are scarce in many of the areas where leprosy is endemic, and even where they are available, hand deformities or poor vision in affected persons make their use difficult. The guiding principles are: amputate only if you must, amputate conservatively and try to provide an end-bearing stump where possible. There is disruption at the midtarsal level with separation of the forefoot from the talus and calcaneum. The talocalcaneal articulation is intact, the talus is plantarflexed and the calcaneum is in equinus. The head of the plantarflexed talus has ploughed through the midfoot and has become directly weight-bearing, as may be seen from the clinical photograph. Because he could feel no pain in the foot, this patient was able to walk on the foot despite the severe damage. Many operations such as joint replacement, spinal fusion and the various types of internal fixation require more specialized implants and instruments to ensure that the bone and implants are correctly aligned and fixed. Surgeons should be familiar with the techniques and implants they plan to use, their advantages and disadvantages and the pitfalls encountered in their use. Most importantly, the surgeon is responsible for ensuring that the necessary instruments and implants (in appropriate sizes! The art and skill of orthopaedic surgery is directed not simply to reshaping or constructing a particular arrangement of parts but to restoring function to the whole. In this chapter, principles applying to orthopaedic operations will be discussed and fundamental techniques of soft-tissue and bone repair will be described. For detailed descriptions of the various operative procedures the reader is referred to standard textbooks on operative orthopaedic surgery and monographs dealing with specific regional subjects. This stage allows the surgeon to plan for appropriate equipment, expertise and support to be available. Before new or complex reconstructive operations are undertaken they should, ideally, be rehearsed using artificial bones and joints at a workbench. Where available, 3D printing of models and mock implants can aid the surgeon preoperatively and in theatre. Fracture reduction, osteotomy alignments and the positioning of implants and fixation devices can be checked before completing the procedure. Although the resolution is not as high as standard radiographs, sufficient detail is normally visible for intraoperative decisions. Smaller low-emission surgeon-operated devices are particularly useful in extremity surgery. Where these are not available radiograph cassettes may be used but must be wrapped in sterile drapes and introduced to the operative field. Angiography may be needed to diagnose a vascular injury or demonstrate the success of a vascular repair. Examples are insertion of screws into vertebral pedicles and positioning of joint replacement components. The recommended dose limit for the general public is 1 mSv per year, which is the equivalent of 1000 chest X-rays. Each chest X-ray in turn produces the same radiation dose as is endured during a 4-hour airline flight. Fluoroscopic images acquired during operations are usually pulsed exposures rather than continuous screening, thus reducing total exposure and amounting to a negligible additional risk of developing cancer. However, for the surgeon the risk is far greater because of the repeated use of fluoroscopy. Total exposure varies with the type of procedure performed (operations on limb extremities produce the least, hip operations, midline and spine operations the most), the number of procedures needing X-ray assistance and the protective measures used. There are a variety of different ways in which surgeons can interact with robots including haptic feedback, force constraint and telemanipulation. The use of robotics in orthopaedics remains relatively rare and is limited by the associated costs. The improved view minimizes the risk of inadvertent injury to structures and allows more accurate apposition of tissues during reconstruction. As the magnification increases, the field of view decreases and the interruption by unwanted head movements becomes more apparent. The operating microscope allows much greater magnification with a stable field of view. It is particularly important when very accurate apposition of tissue is required, for example when aligning nerve fascicles during nerve repair or nerve grafting, when anastomosing small vessels or when operating in a narrow corridor of safety such as in microdiscectomy of the spine. Tied rubber bandages are potentially dangerous and should not be used; the pressure beneath the bandage cannot be controlled and there is a real risk of damage to the underlying nerves and muscle. A protective layer should be applied to the skin prior to placement of the tourniquet. Specifically manufactured devices are now available, but a layer of wool bandage can be used to distribute the tourniquet pressure and cushion underlying skin. During skin preparation, it is essential that the sterilizing fluid does not leak beneath the cuff as this can cause a chemical burn. If a clearer field is required, exsanguination can be achieved by pressure using a rubber tubular exsanguinator prior to skin preparation, or if tourniquet time is to be kept to a minimum, a sterile Esmarch or gauze bandage wrapped from distal to proximal. Traditional concerns about the risk of using adrenaline in the extremities have been overestimated so long as the dose is low enough. This allows the surgeon to assess the effect of a tenolysis, the tension of a tendon transfer, the rotation of a fixed finger fracture throughout range of movement, and the alignment and offset of a small joint replacement. Higher pressures are unnecessary and will increase the risk of damage to underlying muscles and nerves. Tourniquet time Tourniquet time is ischaemia time and thus an absolute maximum tourniquet time of 2. Time can be saved by ensuring that the limb is shaved, prepared, draped and marked before inflating the cuff. Deflating and re-inflating the tourniquet this has serious local and systemic effects. Locally deflation is followed by a hyperaemic response that reduces by half in 5, 12 and 25 minutes, respectively after ischaemic times of 1, 2 and 3 hours. This information is useful to the surgeon trying to obtain haemostasis after tourniquet release. There is also a variable amount of swelling, unrelated to the length of the ischaemic period; it is therefore wise not to use a tourniquet when it is not required to perform the procedure safely and for those limbs where significant swelling is already evident. At the systemic level, tourniquet deflation induces a free radical-mediated reperfusion syndrome, which adds to any muscle damage already produced by the ischaemic period. If a prolonged tourniquet time is required and unavoidable, it is wise to warn the patient of the possibility of transient nerve-related symptoms and to obtain consent to use the absolute maximum period of 3 hours. Shaving before surgery causes superficial skin damage and leads to local bacterial proliferation. This is particularly useful in visibly contaminated cases, managing open fractures and in cases where the limb has been wrapped in a cast or splint for some time. Skin preparation prior to surgery should be carried out with an alcohol-based preparation where safe; alcohol is not to be applied over open wounds, exposed joints or nerve tissue. Iodine or chlorhexidine preparations are available, but there is evidence that chlorhexidine is more effective after a single application, having longer residual activity and maintaining efficacy in the presence of blood and serum. However, use of a red staining fluid should be avoided if a tourniquet is used since it may make it difficult to determine whether blood flow has returned after releasing the tourniquet. A sterile rubber glove-finger makes a good cuff; the tip is cut and the margin is then rolled back proximally. This has the combined effect of exsanguinating the finger and acting as a tourniquet. A rubber glove can be obscured by blood and be left on inadvertently; brightly coloured devices with a long tag are available commercially and indeed in some health services a glove is no longer allowed. A stretched rubber catheter must not be used as this may damage the underlying structures. Always check that the finger tourniquet has been removed at the end of the operation. Drapes Drapes function to isolate the surgical field from the rest of the patient and reduce contamination from outside. Disposable drapes have been shown to be superior at preventing passage of bacteria and strike through of fluids. Plastic adhesive coverings, some impregnated with iodine, function primarily to secure the drapes, Complications Complications of tourniquet usage usually relate to nerve injury (more often due to compression than duration of ischaemia), skin burns from leakage of alcoholic antiseptic solutions beneath the tourniquet cuff and a failure to diagnose peripheral vascular disease before surgery. The risk of these can be minimized by always using a wide cuff, sealing the cuff against seeping fluids and avoiding excessive tourniquet pressures. A wise precaution is to not employ a 320 especially if the limb is moved during surgery. Iodineimpregnated adhesive drapes decrease bacterial counts at the incision site but there is no strong evidence they decrease infection rates. Modern drapes tend to come in packs designed for single use and designed to expose certain areas of the body or for specific operations. Transfer of infectious agents through blood occurs mainly by contact (percutaneous or mucocutaneous) and through aerosols. The face and neck may become contaminated and this may go unnoticed until after the procedure; splashes and aerosol sprays often happen during the use of power tools and irrigation fluids. Exposure is more likely if the operation continues for over 3 hours or when blood loss is greater than 300 mL. This reduces the likelihood of accidental needle-stick injury but is augmented by prophylaxis through vaccination. The latter are needed if either the surgeon or the patient has a latex hypersensitivity. This could apply to patients who are constantly exposed to latex devices such as urinary catheters. Latex allergy is second only to muscle relaxants for inducing anaphylaxis during surgery. Reassuringly, studies have shown that very small penetrations to inner gloves do not lead to significant passage of bacteria. Hepatitis B Transmission may occur through inoculation or even from contact with a contaminated surface (the virus is able to survive for a week in dried blood). There is a 30% risk of transmission from a single inoculation of an unvaccinated person.

An unusually brisk reflex weight loss pills oprah winfrey purchase alli australia, on the other hand weight loss now order alli 60 mg overnight delivery, is characteristic of an upper motor neuron disorder weight loss pills jessica simpson order alli in india. Muscle wasting is important: if localized and asymmetrical weight loss pills you can take while breastfeeding 60 mg alli amex, it may suggest dysfunction of a specific motor nerve weight loss pills ebay alli 60mg low cost. Muscle tone Tone in individual muscle groups is tested by moving the nearby joint to stretch the muscle weight loss supplement xantrax generic alli 60 mg overnight delivery. Increased tone (spasticity) is characteristic of upper motor neuron disorders such as cerebral palsy and stroke. Decreased tone (flaccidity) is found in lower motor neuron lesions; for example, poliomyelitis. Power Motor function is tested by having the patient perform movements that are normally activated by specific nerves. We may learn even more about composite movements by asking the patient to perform specific tasks, such as holding a pen, gripping a rod, doing up a button or picking up a pin. Testing for power is not as easy as it sounds; the difficulty is making ourselves understood. Absence of the reflex indicates an upper motor neuron lesion (usually in the spinal cord) above that level. The plantar reflex Forceful stroking of the sole normally produces flexion of the toes (or no response at all). An extensor response (the big toe extends while the others remain in flexion) is characteristic of upper motor neuron disorders. Stereognosis, the ability to recognize shape and texture by feel alone, is tested by giving the patient (again with eyes closed) a variety of familiar objects to hold and asking him or her to name each object. The pathways for deep sensibility run in the posterior columns of the spinal cord. Disturbances are therefore found in peripheral neuropathies and in spinal cord lesions such as posterior column injuries or tabes dorsalis. If there is no musculoskeletal abnormality to account for the sign, a full examination of the central nervous system will be necessary. Sensibility Sensibility to touch and to pinprick may be increased (hyperaesthesia) or unpleasant (dysaesthesia) in certain irritative nerve lesions. More often, though, it is diminished (hypoaesthesia) or absent (anaesthesia), signifying pressure on or interruption of a peripheral nerve, a nerve root or the sensory pathways in the spinal cord. The area of sensory change can be mapped out on the skin and compared with the known segmental or dermatomal pattern of innervation. If the abnormality is well defined, it is an easy matter to establish the level of the lesion, even if the precise cause remains unknown. The point of hypersensitivity marks the site of abnormal nerve sprouting: if it progresses distally at successive visits, this signifies regeneration; if it remains unchanged, this suggests a local neuroma. Tests for temperature recognition and two-point discrimination (the ability to recognize two touchpoints a few millimetres apart) are also used in the assessment of peripheral nerve injuries. In the vibration test a sounded tuning fork is placed over a peripheral bony point. The sense of joint posture is tested by grasping the big toe and placing it in different positions of flexion and extension. You may have no first-hand account of the symptoms; a baby screaming with pain will tell you very little, and overanxious parents will probably tell you too much. If he or she is moving a particular joint, take your opportunity to examine movement then and there. You will learn much more by adopting methods of play than by applying a rigid system of examination. Infants and small children the baby should be undressed, in a warm room, and placed on the examining couch. If there is no urgency or distress, take time to examine the head and neck, including facial features which may be characteristic of specific dysplastic syndromes. When testing for passive mobility, be careful to avoid frightening or hurting the child. In the neonate, and throughout the first two years of life, examination of the hips is mandatory, even if the child appears to be normal. Older children Most children can be examined in the same way as adults, though with different emphasis on particular physical features. Seldom need anything be done about this; the condition usually improves as the child approaches puberty and only if the gait is very awkward would one consider performing corrective osteotomies of the femora. However, epidemiological studies have shown that they do have a greater than usual tendency to recurrent dislocation. Some experience recurrent episodes of aching around the larger joints; however, there is no convincing evidence that hypermobility by itself predisposes to osteoarthritis. Deformity the boundary between variations of the normal and physical deformity is blurred. Indeed, in the development of species, what at one point of time might have been seen as a deformity could over the ages have turned out to be so advantageous as to become essential for survival. An unusual degree of joint mobility can also be attained by adults willing to submit to rigorous exercise and practice, as witness the performances of professional dancers and athletes, but in most cases, when the exercises stop, mobility gradually reverts to the normal range. Kyphosis and lordosis Seen from the side, the normal spine has a series of curves: convex posteriorly in the thoracic region (kyphosis), and convex anteriorly in the cervical and lumbar regions (lordosis). Excessive curvature constitutes kyphotic or lordotic deformity (also sometimes referred to as hyperkyphosis and hyperlordosis). The position and direction of the curve are specified by terms such as thoracic scoliosis, lumbar scoliosis, convex to the right, concave to the left, etc. Postural deformity A postural deformity is one which the patient can, if properly instructed, correct voluntarily. Structural deformity A deformity which results from a permanent change in anatomical structure cannot be voluntarily corrected. It is important to distinguish postural scoliosis from structural (fixed) scoliosis. The former is non-progressive and benign; the latter is usually progressive and may require treatment. Contracture of the overlying skin this is seen typically when there is severe scarring across the flexor aspect of a joint. Muscle contracture Fibrosis and contracture of muscles that cross a joint will cause a fixed deformity of the joint. Muscle imbalance Unbalanced muscle weakness or spasticity will result in joint deformity which, if not corrected, will eventually become fixed. Joint destruction Trauma, infection or arthritis may destroy the joint and lead to severe deformity. Site A lump near a joint is most likely to be a tumour (benign or malignant); a lump in the shaft may be fracture callus, inflammatory new bone or a tumour. A benign tumour has a well-defined margin; malignant tumours, inflammatory lumps and callus have a vague edge. Consistency A benign tumour feels bony and hard; malignant tumours often give the impression that they can be indented. Tenderness Lumps due to active inflammation, recent callus or a rapidly growing sarcoma are tender. There are a myriad genetic disorders affecting the skeleton, yet any one of these conditions is rare. Acquired deformities in children may be due to fractures involving the physis (growth plate); ask about previous injuries. Other causes include rickets, endocrine disorders, malunited diaphyseal fractures and tumours. Acquired deformities of bone in adults are usually the result of previous malunited fractures. We consider three types of stiffness in particular: (1) all movements absent; (2) all movements limited; (3) one or two movements limited. All movements absent Surprisingly, although movement is completely blocked, the patient may retain such good function that the restriction goes unnoticed until the joint is examined. All movements limited After severe injury, movement may be limited as a result of oedema and bruising. In osteoarthritis the capsule fibroses and movements become increasingly restricted, but pain occurs only at the extremes of motion. Some movements limited When one particular movement suddenly becomes blocked, the cause is usually mechanical. Thus a torn and displaced meniscus may prevent extension of the knee but not flexion. Bone deformity may alter the arc of movement, such that it is limited in one direction (loss of abduction in coxa vara is an example) but movement in the opposite direction is full or even increased. The clinical diagnosis of cartilage-capped exostosis (osteochondroma) is confirmed by the X-rays. Notwithstanding the extraordinary technical advances of the last few decades, it remains the most useful method of diagnostic imaging. The radiographic image X-rays are produced by firing electrons at high speed onto a rotating anode. Articular cartilage Epiphysis Physis (growth plate) Metaphysis Apophysis the more dense and impenetrable the tissue, the greater the X-ray attenuation and therefore the more blank, or white, the image that is captured. Similarly, the bright image of a metallic foreign body superimposed upon that of, say, the femoral condyles could mean that the foreign body is in front of, inside or behind the bone. The process of interpreting this image should be as methodical as clinical examination. It is seductively easy to be led astray by some flagrant anomaly; systematic study is the only safeguard. Make sure that the name on the film is that of your patient; mistaken identity is a potent source of error. The clinical details are important; it is surprising how much more you can see on the X-ray when you know the background. Localized change Focal abnormalities should be approached in the same way as one would conduct a clinical analysis of a soft tissue abnormality. Bulging outlines around a hip, for example, may suggest a joint effusion; and soft-tissue swelling around interphalangeal joints may be the first radiographic sign of rheumatoid arthritis. Tumours tend to displace fascial planes, whereas infection tends to obliterate them. Localized change Is there a mass, soft tissue calcification, ossification, gas (from penetrating wound or gas-forming organism) or the presence of a radioopaque foreign body For example, for the spine, look at the overall vertebral alignment, then at the disc spaces, and then at each vertebra separately, moving from the body to the pedicles, the facet joints and finally the spinous appendages. For the pelvis, see if the shape is symmetrical with the bones in their normal positions, then look at the sacrum, the two innominate bones, the pubic rami and the ischial tuberosities, then the femoral heads and the upper ends of the femora, always comparing the two sides. Are there features suggestive of diffuse metastatic infiltration, either sclerotic or lytic It looks much wider in children than in adults because much of the epiphysis is still cartilaginous and therefore radiolucent. Loose bodies, if they are radioopaque, appear as rounded patches overlying the normal structures. Further stages of joint destruction are revealed by irregularity of the radiographically visible bone ends and radiolucent cysts in the subchondral bone. Bony excrescences at the joint margins (osteophytes) are typical of osteoarthritis. The position of erosions and symmetry help to define various types of arthropathy. In rheumatoid arthritis and psoriasis the erosions are periarticular (at the bare area where the hyaline cartilage covering the joint has ended and the intracapsular bone is exposed to joint fluid). In gout the erosions are further away from the articular surfaces and are described as juxta-articular. Rheumatoid arthritis is classically symmetrical and predominantly involves the metacarpophalangeal and proximal interphalangeal joints in both hands. The erosions in psoriasis are usually more feathery with ill-defined new bone at their margins. Ill-defined erosions suggest active synovitis whereas corticated erosions indicate healing and chronicity. Add to this the typical distribution, more or less symmetrically in the proximal joints of both hands, and you must think of rheumatoid arthritis. Sequential films demonstrate either progression of changes in active pathology or status quo in long-standing conditions. Limitations of conventional radiography Conventional radiography involves exposure of the patient to ionizing radiation, which under certain circumstances can lead to radiation-induced cancer. Ionizing radiation can also damage a developing fetus, especially in the first trimester. As a diagnostic tool, conventional radiography provides poor soft-tissue contrast: for example, it cannot distinguish between muscles, tendons, ligaments and hyaline cartilage.

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