David Childs, MD

• Assistant Professor of Radiology
• Abdominal Imaging Section
• Wake Forest University School of Medicine
• Winston-Salem, North Carolina

The Y lateral view often allows the examiner to detect any posterior displacement of subtle greater tuberosity fractures menstruation taboos safe 2 mg ginette-35. Certain radiographic findings that can suggest that minimally invasive fracture fixation is not appropriate for a given fracture are as follows: Poor bone quality menstruation bowel movements buy ginette-35 cheap. The bone may not hold the pins and screws well and may be better treated with a more stable construct women's health clinic va boise generic 2 mg ginette-35 with mastercard. Comminution of the medial calcar region leads to unstable reduction of the head onto the shaft menopause books ginette-35 2 mg overnight delivery. Fractures amenable to minimally invasive fixation are twopart pregnancy 40 weeks cheap ginette-35 2mg free shipping, three-part 1st menstrual cycle after miscarriage generic ginette-35 2 mg on-line, and valgus impacted four-part fractures with: Good bone quality Substantial fracture fragments with minimal comminution of the tuberosities Minimal or no comminution at the medial calcar region Minimally invasive fixation is not appropriate for noncompliant or unreliable patients. This procedure should be performed only in patients committed to consistent follow-up in the postoperative period. Pin migration is possible and must be caught early in order to avoid potential injury to thoracic structures. The pectoralis major muscle exerts an anterior force on the shaft, resulting in anterior displacement of the shaft relative to the humeral head. Historically, 1 cm of displacement has been used as the criterion for clinically significant tuberosity displacement. Recently, however, even 5 mm of displacement has been considered an operative indication. Patients wear a sling for 2 to 3 weeks or until the proximal humerus feels stable with gentle internal or external rotation of the arm. In borderline instances, it is better to err toward a longer period of immobilization to ensure healing, because shoulder stiffness is easier to address than a nonunion. This image should be checked before prepping and draping to confirm adequate visualization. Instruments can be introduced through this portal to lever fracture fragments or pull fragments into reduced position. By sweeping posterior and superior, the greater tuberosity and its extent of displacement can be palpated. In three- and four-part fractures, the fracture line of the greater tuberosity is reliably 0. Therefore, the reduction portal is located at the level of the surgical neck and 1 cm posterior to the biceps groove. The C-arm is brought in parallel to the patient, leaving the lateral aspect of the arm free for instrumentation. The patient should be positioned laterally on the table such that an adequate fluoroscopic view can be obtained. The C-arm fluoroscope is placed parallel to the patient, extending over the shoulder from the cephalad direction. This position leaves the lateral shoulder completely accessible for instrumentation and pin fixation. The reduction portal is located at the level of the surgical neck fracture approximately 0. A hemostat is applied to the skin (C) and then imaged (D) to confirm that this portal will be directly at the level of the surgical neck fracture. A small incision is made in the skin, and the deltoid is spread bluntly to avoid injury to the underlying axillary nerve. The location of the biceps tendon is estimated based on surface anatomic landmarks. Subcutaneous tissues and the deltoid muscle are spread bluntly using a straight hemostat to avoid injury to the axillary nerve on the deep surface of the deltoid. An axillary or scapular Y radiograph is necessary to evaluate the extent of this displacement. Longitudinal traction is applied to the arm, and a posteriorly directed force is applied to the proximal shaft of the humerus. A blunt instrument can be inserted into the fracture at the surgical neck to lever the head back onto the shaft. This maneuver can be a powerful reduction tool, but care should be used to avoid further damage or fracture to the humeral head during this maneuver, especially on osteopenic patients. The long head of the biceps tendon can become interposed between the fracture fragments, precluding reduction. Therefore, if reduction is not achieved, check the biceps tendon through the reduction portal (or consider open reduction). Pins should be smooth to avoid injury to soft tissue upon insertion, and terminally threaded to avoid backing out. The pins should enter at different directions to enhance stability of fixation construct. One pin should enter lateral to the biceps in a primarily anterior-to-posterior direction. Another pin should enter further laterally in a primarily lateral-to-medial direction. Stability should be checked under fluoroscopic imaging with live, gentle internal and external rotation. The starting point for the pins is approximately 5 to 6 cm distal to the surgical neck fracture line. Often a posterior vector must be applied to the shaft or an instrument can be introduced through the reduction portal to lever the head back onto the shaft. Retrograde pins are introduced several centimeters below the level of the surgical neck fracture into the head. The pins should be placed in different directions to provide stability to the construct. The pins should be cut below the skin after insertion to prevent pin site infection. They are easily removed a couple of weeks later with a small procedure in the office or operating room. Any suggestion of instability or motion at the fracture is an indication for open reduction and plate fixation at that point. The rotator cuff pulls the tuberosity medially (to a certain extent) and posteriorly. Posterior displacement and rotation often are underappreciated and must be considered. The guidewire is passed through the tuberosity, across the surgical neck fracture, and engages the medial cortex of the proximal humeral shaft. A small incision is made over the greater tuberosity, and a cannulated screw is used for fixation. The guidewire is aimed to engage the greater tuberosity fragment as well as the medial cortex to provide compression. Over-tightening should be avoided to prevent fracture of the greater tuberosity fragment. If the greater tuberosity fragment is large enough, a second cancellous screw is directed through the tuberosity fragment, engaging cancellous bone of the humeral head. This fracture configuration results in a low incidence of avascular necrosis compared to that of other fourpart fractures, because the medial periosteal hinge of soft tissues is intact along the medial and posterior anatomic neck, preserving the blood supply provided by the posterior humeral circumflex artery and its ascending vessels. The reduction maneuver for this fracture requires raising the humeral head back into its anatomic position. The instrument passes through the surgical neck fracture and through the fracture line between the tuberosities, which reliably exists 0. The surgical neck fractures and tuberosity fractures are then fixed using the techniques described earlier. Valgus impacted proximal humerus fractures are reduced using a small bone tamp or other blunt-tipped instrument. The instrument is inserted through the fracture line between the greater tuberosity and the lesser tuberosity, which lies posterior to the biceps groove. The bone tamp is impacted in a superior direction, bringing the humeral head into a reduced position. The greater and lesser tuberosities fall naturally into a reduced position after this reduction maneuver. In some cases, there may be significant medial displacement of the lesser tuberosity. In these cases, the lesser tuberosity is reduced using the hook through the reduction portal and fixed with a screw placed in the anterior-to-posterior direction through the tuberosity into the head. In most cases, minimal medial displacement of the lesser tuberosity is well tolerated and no fixation is required. Criteria include good bone stock, minimal to no comminution at the greater tuberosity fragment, minimal to no comminution at the medial calcar and proximal shaft, and patient compliance. Contraindications include poor bone stock that will not hold pins, comminution of greater tuberosity or proximal shaft fragments, and a noncompliant patient with poor follow-up potential. Positioning Reduction technique the patient must be lateral enough on the table to obtain unencumbered access to the shoulder and clear fluoroscopic images. The location of the reduction portal is critical for maximizing its usefulness during the procedure. The surgeon must have a thorough understanding of three-dimensional anatomy, as well as interpretation and application of two-dimensional fluoroscopic images. Pin placement Pins should engage the humerus distal to the axillary nerve, but proximal to the deltoid insertion to avoid nerve injury. The angle of insertion is steep to enter the humeral head and avoid cutting out posteriorly. At least two fluoroscopic images in different planes are necessary to confirm successful pin placement. Screw placement the deltoid should be spread bluntly and a drill guide used to prevent injury to the axillary nerve in this location. In most cases, insertion will be proximal to the nerve, but precautionary measures should be taken. Overtightening the screw with a washer may result in fracture of the greater tuberosity. Engaging medial cortex of the proximal shaft gives stability to the screw construct. Intraoperative assessment of stability the arm should be internally and externally rotated gently under continuous fluoroscopic imagery after completion of hardware placement. Any motion or suggestion of instability is an indication for open reduction and fixation. Pins are removed as a short procedure in the office or operating room about 3 to 4 weeks postoperatively or when early signs of healing are evident radiographically. Pendulum exercises are initiated 2 to 3 weeks postoperatively, and passive stretching (forward elevation in scapular plane), external rotation, and internal rotation (all in supine position) is initiated when pins are removed. Ideally, pins should be out and motion started no later than 4 weeks postoperatively. There were 29 surgical neck, 3 anatomic neck, 8 three-part, and 5 four-part fractures. Keener et al5 reported a multicenter study of 35 patients- 7 two-part, 8 three-part, and 12 valgus impacted fractures. Four patients had some residual malunion, and four developed posttraumatic arthritis. In published studies, patients are not randomized to percutaneous pinning, but, rather, careful patient selection is left to the treating surgeon. Therefore, it can be concluded that this is an appropriate technique in certain patients who meet the outlined criteria. This classification system involves four segments: the articular surface, the greater tuberosity, the lesser tuberosity, and the humeral shaft. Fracture fragments displaced 1 cm or angulated 45 degrees are considered displaced. The subscapularis inserts onto the lesser tuberosity, whereas the supraspinatus, infraspinatus, and teres minor insert onto the greater tuberosity. Knowledge of deforming forces associated with humerus fracture allows the surgeon to better treat proximal humerus fractures by both operative and nonoperative means. In a two-part surgical neck fracture, the pectoralis major pulls the humeral shaft anteromedial. In a two-part greater tuberosity fracture, the pull of the supraspinatus, infraspinatus, and teres minor tendons displaces the greater tuberosity superiorly and/or posteriorly. Three-part fractures involving the greater tuberosity result in unopposed subscapularis function, and the humeral articular surface rotates posteriorly. Four-part fractures result in displacement of the shaft and both tuberosities, leaving a free head fragment with little soft tissue attachment. An understanding of the vascular anatomy is crucial to treat fractures of the proximal humerus effectively. The main blood supply to the humeral head is the anterolateral ascending branch of the anterior circumflex artery. This branch of the axillary artery runs just lateral to the bicipital groove, entering the humeral head at the proximal portion of the transition from bicipital groove to greater tuberosity. Younger patients may sustain such an injury from a higher-energy mechanism such as an automobile collision or from sports. There is less tolerance for displacement in isolated greater tuberosity fractures. It has been suggested that more than 5 mm of displacement leads to poor functional results. Between 6 and 10 weeks, the fracture usually has healed enough that strengthening exercises may be started. Koval et al11 showed significant improvement with one-part fractures when physical therapy was initiated before 2 weeks. Several studies have shown that nonoperative management can lead to acceptable results with proximal humerus fractures.

Endometriosis in the ovary appears as a cystic collection known as an endometrioma menopause 54 generic 2 mg ginette-35 otc. Other common sites include the most dependent parts of the pelvis such as the posterior uterus and broad ligaments menstrual period cup buy ginette-35 2mg without prescription, the uterosacral ligaments breast cancer lasts decades buy cheapest ginette-35 and ginette-35, fallopian tubes women's health clinic ulladulla ginette-35 2mg overnight delivery, colon women's health clinic in abu dhabi ginette-35 2mg online, and appendix menopause age generic 2 mg ginette-35 overnight delivery. Although not commonly found, endometriosis has been identified as far away as the breast, lung, and brain. The Halban theory proposes that endometrial tissue is transported via the lymphatic system to various sites in the pelvis, where it grows ectopically. Meyer proposes that multipotential cells in peritoneal tissue undergo metaplastic transformation into functional endometrial tissue. Finally, Sampson suggests that endometrial tissue is transported through the fallopian tubes during retrograde menstruation, resulting in intra-abdominal pelvic implants. A prevailing theory is that women who develop endometriosis may have an altered immune system that is less likely to recognize and attack ectopic endometrial implants. These women may even have an increased concentration of inflammatory cells in the peritoneum that contribute to the growth and stimulation of the endometrial implants. Endometrial implants cause symptoms by disrupting normal tissue, forming adhesions and fibrosis, and causing severe inflammation. Interestingly, the severity of symptoms does not necessarily correlate with the amount of endometriosis. Women with widely disseminated endometriosis or a large endometrioma may experience little pain, whereas women with minimal disease in the cul-de-sac may suffer severe chronic pain. Women with chronic endometriosis and teenagers with endometriosis may not demonstrate this classic pain pattern. Other symptoms associated with endometriosis are dysmenorrhea, dyspareunia, abnormal bleeding, bowel and bladder symptoms, and subfertility. Endometriosis is one of the most common diagnoses in the evaluation of infertile couples. Over 75% of women with symptomatic endometriosis will have pelvic pain and/or dysmenorrhea. Dysmenorrhea usually begins in the third decade, worsens with age, and should raise concern for endometriosis in women who develop dysmenorrhea after years of pain-free cycles. Dyspareunia is usually associated with deep penetration that can aggravate endometrial lesions in the cul-de-sac or on the uterosacral ligaments. Although the exact mechanism is unclear, moderate to severe endometriosis can cause dense adhesions, which can distort the pelvic architecture, interfere with tubal mobility, impair oocyte release, and cause tubal obstruction. Because surgical confirmation is necessary for the diagnosis of endometriosis, the true prevalence of the disease is unknown. It is found almost exclusively in women of reproductive age, and is the single most common reason for hospitalization of women in this age group. Approximately 20% of women with chronic pelvic pain and 30% to 40% of women with infertility have endometriosis. Physical Examination the physical findings associated with early endometriosis may be subtle or nonexistent. To maximize the likelihood of physical findings, the physical examination should be performed during early menses when implants are likely to be largest and most tender. The most common sites (indicated by blue dots) include the ovaries, the anterior and posterior cul de sacs, the uterosacral ligaments, and the posterior uterus and posterior broad ligaments. When the ovary is involved, a tender, fixed adnexal mass may be palpable on bimanual examination or viewed on pelvic ultrasound. Diagnostic Evaluation When the clinical impression and initial evaluation is consistent with endometriosis, empiric medical therapy is often favored over surgical intervention as a safe approach to management. Note the characteristic "ground glass" appearance of the endometrioma on ultrasound. When surgical intervention is used, endometrial implants vary widely in terms of size, texture, and appearance. They may appear as rust-colored to dark brown powder burns or raised, blue-colored mulberry or raspberry lesions. The areas may be surrounded by reactive fibrosis that can lead to dense adhesions in extensive disease. The ovary itself can develop large cystic collections of endometriosis filled with thick, dark, old blood and debris known as endometriomas or chocolate cysts. Peritoneal biopsy is not absolutely necessary but is recommended for histologic confirmation of the diagnosis of endometriosis. Once the diagnosis of endometriosis is confirmed, the anatomic location and extent of the disease can be used to properly classify the operative findings. Although not commonly used, this classification method uses a point system to stage endometriosis based on the location, depth, and diameter of lesions and density of adhesions. Treatment should be embarked upon with the mindset that the endometriosis is a chronic disease that may require long-term management and multiple interventions. Expectant management may be used in patients with minimal or nonexistent symptoms. In the case of severe or chronic endometriosis, a multidisciplinary approach incorporating medical and surgical management as well as pain center involvement and psychiatric support may provide the most comprehensive care. Medical treatment for endometriosis is aimed at suppression and atrophy of the endometrial tissue. Although medical therapies can be quite effective, these are temporizing measures rather than definitive treatments. Medical management does not improve conception rates and serves only to delay attempts at conception and/or employment of surgical treatments that have been shown to improve conception rates. These treatments induce a state of " pseudopregnancy" by suppressing both ovulation and menstruation and by decidualizing the endometrial implants, thereby alleviating the cyclic pelvic pain and dysmenorrhea. These options are best for patients with mild endometriosis who are not currently seeking to conceive. As a result, the ovaries do not produce estrogen, resulting in decreased stimulation of endometrial implants. Subsequently, existing endometrial implants atrophy, and new implants are prevented. These medications lower circulating estrogen levels by blocking conversion of androgens to estrogens in the ovary, brain, and periphery. The drawback to danazol is that patients may experience some androgen-related, anabolic side effects including acne, oily skin, weight gain, edema, hirsutism, and deepening of the voice. The side effects of these medications are similar to those seen during menopause including hot flashes, decreased bone density, headaches, and vaginal atrophy and dryness. Moreover, these treatments can be costly and often have limited insurance coverage. Women with advanced endometriosis, endometriomas, and infertility may be best served by surgical management. Surgical treatment for endometriosis can be classified as either conservative or definitive. If postsurgical hormone replacement therapy is started after hysterectomy and oophorectomy, some providers will still employ combination hormone therapy due to the theoretical possibility of stimulating transformation of residual implants into an endometrial cancer by the use of estrogen-only replacement therapy. This terminology is no longer used because adenomyosis and endometriosis are two distinct and different clinical entities (Table 15-3). A current theory is that high levels of estrogen stimulate hyperplasia of the basalis layer of the endometrium. For unknown reasons, the barrier between the endometrium and myometrium is broken and the endometrial cells can then invade the myometrium. Endometriomas are best treated using laparoscopic cystectomy with removal of as much of the cyst wall as possible. For these women, the pregnancy rate after conservative surgical treatment depends on the extent of the disease at the time of surgery (Table 15-2). For patients with pain who do not desire immediate pregnancy, pain control can be optimized and recurrences delayed by starting or restarting medical therapy immediately after surgical treatment. Definitive surgical therapy includes total hysterectomy and bilateral salpingo-oophorectomy (by abdominal or laparoscopic approach), lysis of adhesions, and removal of any visible endometriosis lesions. Adenomyomas can also prolapse into the endometrial cavity similar to a classic endometrial polyp. A cystic collection of endometrial cells, old blood, and menstrual debris on the ovary; also known as "chocolate cysts. Also known as fibroids, these benign growths may be located on the intramural, subserosal, or submucosal portion of the uterus. The cyst wall is removed and the ovarian defect is closed or left to heal spontaneously. Because the endometrial tissue in adenomyosis extends from the basalis layer of the endometrium, it does not undergo the proliferative and secretory changes traditionally seen in normally located endometrium or in endometriosis. Adenomyosis may also present as a well-circumscribed, isolated region known as an adenomyoma. These nodular growths may be located in the myometrium or extend into the endometrial cavity. Unlike uterine fibroids, which have a characteristic pseudocapsule, individual areas of adenomyosis are not encapsulated. Instead, adenomyosis can infiltrate throughout the myometrium giving the uterus a characteristic boggy feel on palpation. When symptoms do occur, the most common are secondary dysmenorrhea (30%), menorrhagia (50%), or both (20%). Patients typically present with increasingly heavy or prolonged menstrual bleeding (menorrhagia). They may also complain of increasingly severe dysmenorrhea that may begin up to 1 week before menses and last until cessation of bleeding. Other patients may only experience pressure on the bladder or rectum due to an enlarged uterus. Physical Examination the pelvic examination of a patient with adenomyosis may reveal a diffusely enlarged globular uterus. The consistency of the uterus is typically softer and boggier than the firmer, rubbery uterus containing fibroids. The adenomyomatous uterus may be mildly tender just before or during menses but should have normal mobility and no associated adnexal pathology. About 15% to 20% of patients with adenomyosis also have endometriosis, and 50% to 60% of patients with adenomyosis also have uterine fibroids. Short-term relief has also been achieved using endometrial ablation; however, pain and bleeding recur more frequently when adenomyosis is involved. Endometrial biopsy should be performed to rule out concomitant endometrial hyperplasia and cancer in women >45 before a hysterectomy is performed for adenomyosis. Prior to the surgery, it also is particularly important to distinguish adenomyosis from uterine fibroids. If adenomyosis is mistaken for uterine fibroids, a surgeon attempting a myomectomy may find only diffuse adenomyosis and be forced to perform a hysterectomy instead. This is usually reserved for situations where myomectomy is being planned and it is important to distinguish adenomyosis from uterine fibroids. The hallmark of endometriosis is cyclic pelvic pain, which is at its worst 1 to 2 days before menses and subsides at the onset of flow or shortly thereafter. The severity of symptoms of (dysmenorrhea, dyspareunia, abnormal bleeding, and infertility) may not correlate with extent of disease. Complications of endometriosis include intra-abdominal inflammation and bleeding that can cause scarring, pain, and adhesion formation, which can lead to infertility and chronic pelvic pain. Direct visualization with diagnostic laparoscopy or laparotomy (preferably with histologic confirmation with biopsy) is the only way to definitively diagnose endometriosis. There is no role for the use of medical management in patients trying to conceive or those diagnosed with infertility. Endometriosis can be treated surgically with conservative therapy to ablate implants and lyse adhesions while preserving the uterus and ovaries. Adenomyosis is the extension of endometrial tissue into the myometrium making the uterus diffusely enlarged, boggy, and globular. It occurs in 20% of women, most of whom are parous and in their late 30s or early 40s. Patients typically present with increasing secondary dysmenorrhea and/or menorrhagia; 30% of patients are asymptomatic. Patients age 45 and older with abnormal uterine bleeding should also have an endometrial biopsy to rule out hyperplasia and cancer. Hysterectomy is the only definitive means of definitively diagnosing and treating adenomyosis. You explain how it works and that the side effects include all of the following except: a. In particular, she has noticed more pain on her left side in the last couple of months. She denies any changes in her bladder or bowel habits but reports that she has begun to have pain with deep penetration during intercourse. She has had only one lifetime sexual partner and no history of sexually transmitted infections. On examination, she has no abnormal discharge but her uterus is tender as well as her left adnexa.

Other important aspects of the history include: Previous history of injury to the affected shoulder Previous shoulder function History of numbness or tingling in the affected extremity Rule out elbow and wrist fractures menstrual 3 times in 1 month ginette-35 2mg on-line, especially in osteoporotic patients with injuries resulting from a fall on an outstretched arm menstrual pads discount 2mg ginette-35 fast delivery. Examination should include skin integrity womens health lebanon pa generic 2mg ginette-35, presence of ecchymosis menstruation headache ginette-35 2mg visa, downward carriage of shoulder girdle womens health diet order ginette-35 2mg overnight delivery, and deformity consistent with shoulder dislocation or acromioclavicular joint separation breast cancer markers buy ginette-35 amex. Possible associated vascular injury can be determined by testing radial pulse and capillary refill. A complete series with these views allows the fracture configuration to be determined in sufficient detail. It also is helpful if there is any question of joint dislocation or glenoid fracture. Radiographs are used to determine whether the fracture is a two-, three-, or four-part fracture and to assess the degree of displacement. Elderly individuals often sustain proximal humerus fractures as the result of low-energy injuries such as slipping and falling. These injuries often are very amenable to minimally invasive fixation techniques, because the displacement is manageable and the periosteal sleeve between fracture fragments often is intact. If the shaft and the proximal portion move as a unit when taken through internal and external rotation, the fracture usually is stable. If there is an associated dislocation, it may be possible to palpate the humeral head as an anterior fullness. It is crucial to perform a thorough neurovascular examination to determine the presence of associated injuries. One study demonstrated nerve injury, usually of the axillary nerve, in nearly 40% of patients in this age group who sustained shoulder dislocations or surgical neck fractures. Additional views also may include internal and external rotation views if the fracture pattern is stable. Internal rotation views help to visualize the lesser tuberosity, whereas external rotation shows the greater tuberosity. Patients also must be aware of the importance of physical therapy postoperatively. Each proximal humerus fracture is unique, and in most cases a planned method of fixation is chosen before entering the operating room. However, the definitive choice of fixation is not made until the fracture is visualized at surgery. Consequently, the surgeon should be prepared with an arsenal of different fixation techniques. If the fracture is not deemed suitable for internal fixation intraoperatively, the surgeon must be prepared to perform a hemiarthoplasty. Multiple techniques can be employed for surgical fixation of the proximal humerus. Positioning the techniques discussed in this section are easiest to perform with the patient in the beach chair position. Approach the approach depends on the surgical technique to be used and is discussed further in the Techniques section. An incision is made from the tip of the acromion extending laterally down the arm. Alternatively, an incision can be made parallel to the lateral border of the acromion, as used in open rotator cuff repair. The deltoid is split in line with its fibers, and the anterior portion of the deltoid may be detached from the acromion. The deltoid fibers should not be split further than 5 cm below the acromion, to prevent damage to the axillary nerve. A suture at the distal aspect of the split can help prevent inadvertent extension. Abducting and externally rotating the shoulder will take tension off the posterosuperior rotator cuff, allowing the greater tuberosity fragment to be more easily reduced. Cannulated screws placed over the wire may then be used for definitive fixation if placed in an acceptable location. Alternatively, suture fixation of the greater tuberosity back to the humerus may provide better fixation than cannulated screws in those patients with poor bone quality. If the anterior deltoid was detached during the approach, it must be repaired back to the acromion using nonabsorbable sutures. Traction sutures are placed through the rotator cuff tendon to aid in reduction of the displaced greater tuberosity. Screws should obtain purchase in the far cortex, but they must not be long enough to damage the axillary nerve. Depending on the pattern, the fracture may be approached via the deltopectoral interval or a deltoidsplitting approach. This "interval split" allows visualization of the humeral head articular surface, if needed, in the setting of intact tuberosities and rotator cuff, as with head split patterns. Multiple sutures are placed through the tendons of the rotator cuff, preferably no. With three-part fractures involving the greater tuberosity, the head fragment should first be secured to the shaft, followed by reduction of the greater tuberosity. Sutures are placed through the subscapularis as well as the posterosuperior rotator cuff tendons at the muscle tendon junction. The plane between the deltoid and pectoralis major is developed, mobilizing the cephalic vein. The incision is made extending from the coracoid process distally along the deltopectoral groove. Using two Cobb elevators to develop the interval, bringing the cephalic vein laterally. The underlying clavipectoral fascia is identified and incised laterally to the conjoined tendon. The pectoralis major insertion is elevated in a subperiosteal fashion if necessary. Often, it may be necessary to release a small portion of the anterior deltoid insertion before placing the plate. Heavy sutures may be placed through the insertions of the cuff tendons and later used as supplemental fixation if necessary. For fractures with minimally displaced tuberosities, sutures may not be needed before a reduction maneuver. Plate Fixation Fluoroscopy should be used to confirm the reduction before placement of the plate, especially in regard to the superior aspect of the plate. A plate positioned too high or a fracture fixed in varus may result in the plate impinging on the undersurface of the acromion. Traction sutures through the tendinous attachments of the rotator cuff may be helpful in correcting varus deformity. Note the position of the superior aspect of the plate in relation to the top of the tuberosity. Locking screws usually are placed proximally into the head first, and multiple configurations of screws are possible. Sutures placed through the cuff tendons also may be secured to the plate, shaft, or other tuberosity. At the completion of the procedure, the pectoralis major may be secured with sutures through holes in the plate. In osteoporotic bone, the tuberosities can first be attached to the shaft with sutures, following which a locking plate may be placed along the lateral aspect of the proximal humerus. Fixation of displaced two-part proximal humerus fractures also can be performed using a locking plate in a percutaneous fashion. With this technique, great care must be taken to prevent injury to the axillary nerve. A recent cadaveric study8 demonstrated that the axillary nerve was an average of 3 mm from the second most proximal diaphyseal screw hole, and an average of 7 mm from the third most proximal screw hole. Development of the "interval split" aids in fracture visualization and reduction and does not require detachment of the rotator cuff tendons. This is especially helpful when trying to fix a headsplitting fracture in a young patient. With suture fixation, the strong bone along the bicipital groove of the distal fragment will hold sutures the best. Maintaining fixation Poor bone quality With osteoporotic three-part fractures, consider suture fixation first, followed by a proximal humeral locking plate. Superior impingement Avoid placing the locking plate too high on greater tuberosity. A physical therapy regimen should be established based on the stability of fixation, the fracture pattern, the quality of the bone, and individual patient factors. Ideally, the fixation should allow pendulum exercises on the first postoperative day and 130 degrees of passive forward flexion and 30 degrees of passive external rotation. Between 4 and 6 weeks after surgery, an overhead pulley can be added, with stretching and active motion added at 6 to 8 weeks. Formal strengthening with elastic bands is not started until 10 to 12 weeks after surgery. In a recent study looking at fixation of two- and threepart fractures, the only patients with unsatisfactory outcomes were those who were noncompliant with physical therapy. Evaluation of the Neer system of classification of proximal humeral fractures with computed tomographic scans and plain radiographs. Nerve injuries in dislocations of the shoulder joint and fractures of the neck of the humerus. The translated two-part fracture of the proximal humerus: Epidemiology and outcome in the older patient. Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. A cadaveric study to evaluate the safety of percutaneous plating of the proximal humerus. Functional outcome after minimally displaced fractures of the proximal part of the humerus. Two-part and three-part fractures of the proximal humerus treated with suture fixation. The influence of displacement on shoulder function in patients with minimally displaced fractures of the greater tuberosity. Some authors believe that greater tuberosity displacement of greater than 5 mm may lead to poor outcomes. McLauglin14 first suggested that patients in whom a greater tuberosity healed with residual displacement of more than 5 mm had longstanding pain with poor function. Platzer et al21 looked at minimally displaced fractures of the greater tuberosity and found no statistical significance with varying degrees of displacement less than 5 mm. Open reduction with suture or wire fixation can achieve acceptable fixation, especially in older patients with osteoporotic bone. One study showed nearly 80% excellent results with average motion of 155 degrees of average forward flexion, 46 degrees average external rotation, and internal rotation to T11. Recent studies show promise with the use of such locking plates, although this technique is not without complications. The reproducibility of classification of fractures of the proximal end of the humerus. Conservative treatment of fractures and fracture-dislocations of the upper end of the humerus. Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients. Numerous techniques of internal fixation for proximal humerus fractures have been described and reported, including cloverleaf and blade plating,1 Rush pinning,15,19 spiral pinning,18 Kirschner wire and tension band fixation,3 suture and external fixation,7 and intramedullary nail fixation. Various reports have been made on the use of intramedullary nails in the proximal humerus. The method for treatment of proximal humeral fractures described in this chapter involves a minimally invasive anterior acromial surgical approach, an indirect method of reduction, and a unique intramedullary rod designed to permit a variety of proximal interlocking configurations. Vascular Supply of the Proximal Humerus the anterior and posterior humeral circumflex arteries are branches of the axillary artery. The arcuate artery, the terminal vessel of the ascending branch of the anterior humeral circumflex artery, supplies most of the humeral head. Avascularity of the humeral head can occur if this vessel is disrupted during a fracture of the anatomic neck. The posterior circumflex artery becomes important in patients with proximal humerus fractures. It may be the primary source of blood supply to the fractured head, so care should be taken to prevent additional devascularization. Traumatic and iatrogenic vascular insult may lead to devascularization of the fracture fragments, resulting in delayed union, nonunion, and avascular necrosis. Traumatic injury cannot be predicted; well-planned minimally invasive procedures should reduce the risk of further damage, however. Innervation the brachial plexus is at risk in patients with upper extremity injury, and thorough neurologic evaluation is mandatory. The position of the head is higher than the tuberosities, and changes in this relationship will cause impingement. The humeral head is retroverted approximately 30 degrees (range 20 to 60 degrees).

Even rarer causes include post-carotid endarterectomy and post-catheterization of the internal jugular vein womens health orlando purchase generic ginette-35 on-line. Radiating arm pain is thought to be the result of traction on the brachial plexus caused by drooping of the shoulder girdle contemporary women's health issues for today and the future 5th edition pdf discount ginette-35 2mg overnight delivery. Its function is to elevate and rotate the scapula; absence of the trapezius leads to lateral winging of the scapula women's health center norman ok buy 2mg ginette-35 overnight delivery. Functionally women's health vs shape magazine generic ginette-35 2 mg amex, the trapezius can be divided into three separate parts: upper menstruation kolik purchase ginette-35 2 mg on-line, middle womens health zephyrhills fl ginette-35 2 mg generic, and lower. The upper portion consists of descending fibers and functions as an aid to suspension of the shoulder girdle, allowing shrugging of the shoulder. The middle portion consists of transverse fibers and contributes to abduction and rotation of the inferior angle of the scapula. The ascending fibers of the lower portion (along with the serratus anterior) anchor the scapula to the chest wall. Schematic of the three parts of the normal trapezius muscle: upper, middle, and lower. Schematic of trapezius palsy, demonstrating lateral scapular winging and shoulder drooping. Although nonoperative management can provide reduction of pain, it does not lead to return of function, and patients treated without surgery usually go on to progressive shoulder dysfunction. Typically, the initial presentation is acute shoulder pain without palsy, with weakness of anterior elevation and abduction appearing after a few days (with slow diminution of pain). The patient should be observed from behind so comparison can be made with the contralateral side. Symptoms include weakness made worse by prolonged use of the arm, a feeling of a heavy arm, and a dull pain radiating from the scapula to the forearm (and occasionally with radiation to the hand). The radiation of pain is described as mimicking thoracic outlet syndrome (medial aspect of the upper limb). Pain typically is made worse by abduction of the shoulder as well as forward elevation. Range of motion is decreased in elevation as well as abduction, and typically is limited to 90 degrees. As a result, overhead activities are not possible, nor is shrugging of the shoulder. Anterior sternocleidomastoid muscle wasting due to the spinal accessory nerve palsy. Romero and Gerber13 state that patients did not always present with a stiff shoulder but passive range of motion typically was decreased. On the other hand, Teboul et al16 report that patients often presented with stiffness but with no deficit in passive range of motion. The necessity for electrodiagnostic testing is an issue of debate in the literature. Evaluate the scapula for signs of lateral translation by asking patient to perform a wall push-up. Strengthening of the remaining scapulothoracic muscles does not compensate for the trapezius deficit, and, in one study, patients who elected nonoperative management could not elevate their arms above the horizontal. Timing of the repair attempt is controversial; some authors believe that repair should only be attempted if diagnosis is confirmed within 6 months of injury,14 whereas other surgeons advocate repair up to 20 months from the time of the nerve insult. Typically, however, reconstructive surgery is recommended if more than 12 months has elapsed since the injury. Because the rhomboid major and minor and levator scapulae have medial insertions, they are not capable of stabilizing the scapula unless they are transferred laterally. Electrodiagnostic testing is recommended in every case, according to Setter et al. Preoperative Planning It is imperative to have appropriate preoperative discussions with the patient so that he or she understands the procedure, the postoperative rehabilitation program, and the timeframe within which improvement should be expected. Other possible types of shoulder dysfunction that may confuse the issue include serratus palsy and rotator cuff pathology. It is crucial to be able to differentiate between spinal accessory nerve (trapezius) palsy and long thoracic nerve (serratus) palsy. In serratus palsy, the inferior angle of the scapula rotates medially, whereas in trapezius palsy, the inferior angle of the scapula rotates laterally. Positioning the patient is placed in the lateral decubitus position with thoracic, pubic, and sacral supports. The major incision is made along the medial border of the scapula, extending superiorly to allow exposure to the levator scapula, rhomboid minor, and rhomboid major for their planned transfers. The levator scapula, rhomboid minor, and rhomboid major are identified and individually released from their scapular attachment sites for lateral transfer. The supraspinatus and infraspinatus are elevated at least 5 cm medially to allow appropriate exposure of the scapula. In this modification, the new position of the rhomboid minor more efficiently substitutes for the middle part of the trapezius. A series of drill holes are made, and transosseous sutures are placed in preparation for securing the transferred muscles. The rhomboid minor and major are transferred to the supraand infraspinous fossae, respectively. Normal position of the levator scapula, rhomboid minor, and rhomboid major on the medial border of the scapula. This modification includes transfer of the rhomboid minor to the supraspinatus fossa. The levator is then transferred subcutaneously and affixed with a series of heavy nonabsorbable sutures. The infraspinatus muscle is then sutured over the new rhomboid muscle insertions and, finally, the wounds are closed in layers. The second incision is made 5 to 7 cm medial to the posterolateral corner of the acromion for transfer of the levator scapula muscle. Excursion of the levator is confirmed before the muscle is subcutaneously tunneled to the planned transfer site. The infraspinatus and supraspinatus are elevated from their respective fossae for approximately 5 cm. This modification of the original procedure permits the rhomboid minor to be transferred to a position that better substitutes for the action of the middle trapezius. Care should be taken to prevent injury to the suprascapular nerve, which lies on the deep surface of the supraspinatus muscle. Levator transfer Dissect the levator scapula far enough laterally to allow tension-free transfer to the scapular spine. Avoid iatrogenic injury to the transverse cervical artery and the dorsal scapular nerve, which run superficial and deep, respectively, to the levator scapulae and then terminate into the deep surface of the rhomboids near their insertion onto the scapula. A tunnel is created through the atrophied trapezius, in line with its upper fibers, for passage of the tagged levator scapulae. The levator should not be transferred too far laterally, because this can cause a web-like deformity in the neck. Our routine postoperative protocol is to use a foam wedge or orthosis for the first 4 weeks, keeping the arm in 60 to 70 degrees of abduction. We encourage early passive range of motion above the wedge or orthosis to prevent stiffness (forward elevation to 130 degrees and external rotation to 40 degrees in the first 4 weeks). At 4 weeks, the wedge is discontinued, and gentle strengthening exercises are added. We have designed a progressive strengthening program that uses rubber tubing, free weights, and medicine ball throws to achieve dynamic scapular stability. All of the exercises in the protocol are designed to strengthen the transferred levator scapula and rhomboids. Such a complication is discussed rarely, and we were only able to find one report of a failure of muscle integration. Initial complications do not seem to be the problem with the Eden-Lange procedure; rather, the primary complication appears to be later effects of functional outcome falling short of expectations. Iatrogenic dysfunction resulting from no longer having a physiologic levator scapula or rhomboids is not, to our knowledge, discussed in the literature. However, because the origin of these muscles is merely being transposed more laterally, it does not appear that the Eden-Lange procedure creates a new problem while fixing the old one. In cases of failure of the procedure, where pain and dysfunction continue, scapulothoracic arthrodesis can be performed as a salvage procedure. In a study in which 16 patients were reviewed at a mean follow-up of 32 years, clinical outcomes were noted to be excellent in 9 patients, fair in 2 patients, and poor in 1 patient (as determined by Constant score). This measurement was compared to the contralateral side, and no statistical differences were found. Another recent study16 concluded that muscle transfer should be performed only after previous nerve repair surgery had failed or when more than 20 months has elapsed since the injury was incurred. In this series of 7 patients treated with the Eden-Lange procedure (the other 20 patients were treated with nerve surgery), results were excellent in 3 patients, good in 1 patient, and poor in 3 patients. Transfer of the levator scapulae, rhomboid major, and rhomboid minor for paralysis of the trapezius. Spinal accessory nerve injury as a complication of internal jugular vein cannulation. Trapezius paralysis after minor surgical procedures in the posterior cervical triangle. Levator scapulae and rhomboid transfer for paralysis of trapezius: the Eden-Lange procedure. Lesions of the long thoracic nerve can range from paresis to complete paralysis, leading to varying degrees of shoulder dysfunction. The serratus anterior muscle functions to stabilize the scapula against the chest wall, thus providing a fulcrum for the humerus to push against while moving the arm in space. Forward elevation of the shoulder is most severely affected, followed by shoulder abduction. It has digitations that take origin from the upper nine ribs, pass deep to the scapula, and insert on the medial aspect of the scapula. This division runs slightly upward and inserts on the superior angle of the scapula. The second division is made up of three slips from the second, third, and fourth ribs, and inserts on the anterior surface of the medial border of the scapula. The third division, which consists of the inferior five slips from ribs five through nine, inserts on the inferior angle of the scapula. Because this division has the longest course it has the longest lever-arm and the most power for scapular rotation. The serratus anterior muscle stabilizes the scapula against the chest wall, creating a fulcrum for the proximal humerus to lever against while moving the arm in space. The inferior border of the scapula is pulled forward with forward elevation of the arm. This causes the glenoid to tip posteriorly and allow full forward elevation without impingement. The C5 and C6 roots pass through the scalenus medius muscle and merge before they receive a branch from C7. The nerve enters the axillary sheath at the level of the first rib and travels posteriorly in the axilla. Proximally, as well as distally along the chest wall, the nerve is susceptible to injury because of its superficial location. The nerve is tethered in the axillary sheath, which places it on stretch with forward elevation of the arm. Congenital absence or traumatic rupture of the parascapular muscles Scapulothoracic bursitis Secondary winging may occur following disorders of the glenohumeral joint. The sequence of events leading to secondary scapular winging due to primary shoulder pathology is as follows: Primary glenulohumeral or subacromial pathology, leading to Limited glenulohumeral motion, leading to Increased compensatory scapulothoracic motion, leading to Increased demand on periscapular muscles, leading to Fatigue of periscapular muscles-serratus, trapezius, and rhomboids-leading to Secondary scapular winging Voluntary winging may occur in psychiatric patients or for secondary gain. Long Thoracic Nerve Palsy Long thoracic nerve palsy is the most common cause of serratus dysfunction resulting in symptomatic scapular winging, especially in those patients who fail nonoperative management and are being considered for pectoralis tendon transfer. Lesions also may occur through entrapment of the fifth or sixth cervical roots at the level of the scalenus medius, during traction over the second rib, or with traction and compression at the inferior angle of the scapula with general anesthesia or prolonged abduction of the arm. Often, the cause is idiopathic, with a questionable history of trauma or viral illness. Pathoanatomy A mechanical advantage is gained by stabilization of the scapula against the chest wall. With loss of this mechanical advantage, forward elevation against resistance is decreased owing to scapulothoracic motion. Most cases resolve spontaneously without operative intervention within 12 months, although maximal recovery may take up to 24 months. Treatment often is delayed, and diagnosis may become apparent only after failed treatment for other disorders. Furthermore, patients may develop secondary stiffness from disuse, and this may be the primary complaint. Patients often present with vague complaints of shoulder pain or weakness with overhead activities. Because winging may be subtle, the patient must be undressed from the waist up, viewed from the back, and tested with provocative maneuvers such as resisted forward elevation and pushups against a wall. Pain may come from several sources, making diagnosis of long thoracic nerve palsy based on pain distribution difficult. Compensatory overuse of the remaining scapulothoracic musculature may cause pain localized posteriorly about the scapula. In secondary winging, pain may result from an underlying diagnosis such as glenohumeral instability. With severe pain, long thoracic neuritis or ParsonageTurner syndrome should be considered.

Order cheapest ginette-35. I'm GIVING BIRTH HERE!! HOSPITAL TOUR!.