Robert A. Frantz, MD

• Assistant Professor of Anesthesiology
• Department of Anesthesiology
• Cedars-Sinai Medical Center
• Los Angeles, California

Burnand Many of the problems caused by diseases of the arteries treatment for dogs gum disease discount sumycin online american express, veins and lymphatics are common to all of the causative diseases staph infection generic sumycin 250mg with mastercard. Dysfunction the pain antibiotic use in animals purchase generic sumycin canada, swelling and deformities caused by the vascular diseases listed in Table 11 antibiotics wiki cheap sumycin 250mg visa. Most are associated with degenerative arterial disease but some are related to Table 11 treatment for dogs broken toe cheap sumycin online mastercard. Investigations provide only confirmatory information and guidance for further management antibiotic resistant ear infection discount sumycin 500mg fast delivery. Venous abnormalities associated with venous hypertension cause intradermal deposition of haemosiderin giving the skin a deep brown colour. Although they may have made a correct diagnosis, investigations may be needed to ascertain the cause (Table 11. Less commonly, it is the Swelling/oedema There are many causes of swelling of the lower limb, local vascular and general medical (Table 11. The diagnosis of oedema is made by showing that the swelling pits with direct digital pressure. When the leg is severely ischaemic there will be progressive loss of nerve function leading to paraesthesia and paralysis, ultimately leading to tissue death. A cuff is placed around the lower leg and inflated until the Doppler signal disappears in the pedal vessels. In cases where embolism is highly likely on clinical grounds and the limb is threatened, it is reasonable to attempt revascularization without further imaging. Fixed staining of the skin, muscle rigidity or loss of function are indicators of tissue death. Acute aortic dissection is usually accompanied by severe chest, abdominal, and back pain. Imaging Imaging investigations are not always necessary when the survival of the limb is threatened. The aim of imaging is to establish the site of the vascular occlusion and the presence of distal vessels in case bypass is necessary. Haematology A full blood count excludes polycythaemia or thrombocytosis/thrombocythaemia. Anticoagulation may be indicated to reduce the progression of a thrombotic vessel occlusion if the extent of limb loss is uncertain. Results of palliative care Conservative management of an acutely ischaemic limb results in a high early mortality, from a combination of septicaemia, multiorgan failure and complications of immobility. Biochemistry the serum potassium may be raised if there has been significant prolonged ischaemia. Procedure After angiography has been performed to confirm the site and nature of the occlusion a perfusion catheter is positioned within the vessel or graft adjacent to the thrombus. Emergency care Patients should receive adequate analgesia and fluid replacement if dehydrated. The circulation should be optimized to maximize perfusion and oxygen delivery to the affected limb. Once thrombolysis is successful a cause for the occlusion should be sought and treated. Surgical treatment Urgent surgical intervention to save the limb is required in many patients with acute lower limb ischaemia. Depending on the cause and the underlying disease in the vessels, treatment can range from a simple femoral embolectomy to a distal bypass procedure. Careful clinical assessment with appropriate imaging can help predict what procedure will be necessary but the patient should be consented and prepared in the operating room for any of the following procedures. Femoral embolectomy can be performed under local anaesthetic in frail patients or those with significant co-morbidity. Regional anaesthesia (epidural or spinal) may be considered but may not be possible if anticoagulants have already been given. An operating table suitable for on-table angiography should be used and radiographers alerted. Complications Haemorrhage the patient must be monitored for haemorrhagic complications. Amputation is likely to be necessary if the limb is not viable or if revascularization fails. The surgical procedure required for acute ischaemia after trauma depends on the type and extent of the injury. Transection or more extensive injuries may require interposition or bypass grafting. Anticoagulation is initiated with intravenous unfractionated or subcutaneous low molecular weight heparin followed by warfarin provided there are no contraindications. Early complications Compartment syndrome is the progressive increase in pressure in one or several of the muscle compartments. It can be caused by a period of acute ischaemia especially from the tissue swelling that follows revascularization. It causes severe pain, characteristically exacerbated by passive movements, and tense tender compartments. Patients present with a recurrence of the symptoms of acute ischaemia or symptoms of chronic ischaemia (see below). Imaging with ultrasound or X-rays may show fluid and sometimes gas around the graft. Graft infection can be treated conservatively with long-term antibiotics if the infection is not aggressive and the anastomosis intact; if not, the graft should be removed and an alternative revascularization procedure performed. Symptomless peripheral vascular disease Patients without vascular problems are often found to have evidence of peripheral vascular disease on routine examination. Management No specific investigations or treatment are indicated but there is good evidence that these patients should be prescribed antiplatelet agents and statins to reduce the chance of cardiovascular events. Smoking should be stopped and any diabetes, hypertension and hyperlipidaemia treated. Intermittent claudication Investigation Clinical diagnostic indicators Cramp-like muscle pain that occurs after a relatively fixed amount of exercise and is relieved by Management options Treatment decisions are based on the balance between the potential benefits and the risks of intervention. Intervention should only be considered for patients with relatively short distance claudication that is having a significant detrimental effect on their quality of life or when there is incipient critical limb ischaemia. One-third experience a progressive deterioration of symptoms, sometimes in a stepwise fashion as more vessels occlude. Only about 5 per cent go on to develop critical limb ischaemia, and only 1 per cent eventually come to amputation. Surgical treatment this should be considered if the claudication is significantly impairing the quality of life or the walking distance is very short. Regular controlled, supervised walking exercises have been shown to improve walking distance, and raising the heel of the shoe sometimes helps. Flow measurement Duplex ultrasound can be used as an initial assessment, but more detailed imaging will always be necessary as intervention is obligatory to avoid limb loss. Post-operation care Antiplatelet and statin medication is advised unless there are contraindications. Complications Angioplasty may fail if it is not possible to cross the lesion with a wire or balloon, or if the lesion is resistant to dilation. Prophylactic angioplasty should be performed to prevent occlusion if a severe (50 per cent) stenosis develops. Surgical treatment Patients with critical limb ischaemia often have multiple co-morbidities, particularly coronary artery, respiratory and renovascular disease. A sheath is inserted into the femoral artery using the Seldinger technique either in a retrograde or antegrade direction. This technique has allowed the treatment or long segments of disease with apparently good results in some centres. The best conduit for long-term patency and resistance to infection for a femoropopliteal or femoral-distal bypass is an autogenous superficial vein. Post-operation care the patient should be monitored for any signs of post-operative bleeding or infection. The circulation of the limb should be carefully observed to detect early graft occlusion. Complications Restenosis may occur soon after angioplasty as a result of vessel recoil and later as a result of intimal hyperplasia and recurrent atheroma. If there are no contraindications, thrombolysis may successfully open the graft if it has thrombosed within a week of presentation. Sometimes infection can be kept dormant with antibiotics but prosthetic material is resistant and the graft may need to be removed. Small areas of dry gangrene may be allowed to demarcate and auto-amputate, but must be monitored closely for developing infection. As the retraction and neovascularization of the thrombus is variable, the vein lumen may remain totally or partially occluded or become completely recanalized. Part or all of the thrombus may break off to form an embolus that usually travels to the lungs. Small pulmonary emboli may be symptomless, although, if multiple, may result in chronic pulmonary hypertension. Large emboli may obstruct the pulmonary arteries and cause acute heart failure and death. Triggering of the coagulation cascade results in deposition of alternate layers rich in platelets and erythrocytes embedded in a fibrin mesh giving a characteristic laminated appearance. Small thrombi may be removed by the endogenous thrombolytic activity of the blood, but more commonly a process of tissue organization occurs within the thrombus that begins immediately and evolves over several months. An acute inflammatory response in the vein wall is followed by migration of inflammatory cells into the thrombus. Polycythaemia and thrombocytosis predispose to thrombosis, and must be investigated. Contrast venography has a high sensitivity and specificity for occluded vein segments and is the most accurate method of assessing post-thrombotic changes. Genetics Genetic tests may include those for the inherited thrombophilias as above. It can reduce the damage to the veins and the incidence of post-thrombotic symptoms but is only effective within the first 2 weeks after thrombus formation. During and after the infusion the patient needs to be monitored for haemorrhage, which often manifests itself as oozing around the catheter site but may be intracranial and fatal. Venous gangrene should be managed conservatively for as long as possible as the necrosis is often superficial and deep tissues will survive. Results Successful thrombolysis may reduce the incidence of post-thrombotic symptoms. Their symptoms include pain, swelling, the skin changes of lipodermatosclerosis, and ultimately ulceration. Surgical thrombectomy is rarely performed as the incidence of rethrombosis is high. The common femoral vein is exposed and the thrombus removed with a balloon embolectomy catheter. A temporary arteriovenous fistula can be created to reduce the incidence of rethrombosis. Arthritis tends to cause pain as soon as exercise begins rather than after a distance as in claudication. Passive hip, knee or ankle movements may be painful and straight leg raising limited. Abdominal aortic aneurysm 249 Blood tests these are needed to exclude serum positive autoimmune causes of inflammatory arthritis. Saccular aneurysm Management the management of the common spinal conditions that produce symptoms that mimic intermittent claudication are described in Chapter 10. The clinical degree of vascular disease is not usually compatible with being a cause for the symptoms. The incidence of rupture Investigation Clinical diagnostic indicators Patients are usually current or prior smokers and often have a history of hypertension. Most abdominal aortic aneurysms remain symptomless until they rupture, but some are detected incidentally either on examination or when the patient undergoes imaging for other reasons. Pain or tenderness suggests incipient rupture and is an indication for urgent surgical repair. Sudden onset of central abdominal or back pain with signs of hypovolaemic shock is indicative of rupture. There is a re-intervention rate of between 10 and 20 per cent by 3 years compared with less than 5 per cent at 5 years with open surgery. All patients should be treated with antiplatelet agents, a statin, and blood and diabetes controlled. Conservative treatment In the presence of significant co-morbidity it may be decided that the (B) (A) Duplex ultrasound assessment of the size of an aortic aneurysm. Open surgical repair this is indicated if the aneurysm is painful or tender, has a diameter greater than 5. The aneurysm sac is opened and back bleeding from lumbar or mesenteric vessels controlled.

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Symptomatic viral myocarditis may be secondary to continued viral replication and/or autoimmune activation following viral infection antibiotic resistance symptoms buy discount sumycin 500 mg on line. A pericardial friction rub may be audible in patients with associated pericarditis antibiotic 7 days to die sumycin 250 mg without a prescription. The isolation of virus from the stool antibiotic resistant bacteria in meat purchase 250mg sumycin overnight delivery, pharyngeal washings virus in michigan order 500mg sumycin otc, or other body fluids and changes in specific antibody titers may be helpful clinically antibiotic 24 order sumycin 250 mg with visa. Endomyocardial biopsy antibiotic resistance usda buy generic sumycin canada, carried out early in the illness, may show round-cell infiltration and necrosis of adjacent myocytes. Although viral myocarditis is most often self-limited and without sequelae, severe involvement may recur. Diphtheritic myocarditis develops in over one-quarter of patients with diphtheria; it is one of the more serious complications and the most common cause of death in this infection. Cardiac damage is due to the liberation of a toxin that inhibits protein synthesis and leads to a dilated, flabby, hypocontractile heart. Prompt therapy with antitoxin is critical; antibiotic therapy is also indicated but is of less urgency. At necropsy, the distinctive features include cardiac enlargement, ventricular thrombi, grossly visible serpiginous areas of necrosis in both ventricles, and microscopic evidence of giant cells within an extensive inflammatory infiltrate. The etiology of giant cell myocarditis has not been identified, although an autoimmune cause appears to be likely. While treatment with immunosuppressive therapy may help some patients, cardiac transplantation is often necessary. About 10% of patients develop symptomatic cardiac involvement during the acute phase of the disease. Intravenous ceftriaxone or penicillin is indicated in all but the mildest forms of Lyme carditis, in which case oral amoxicillin or doxycycline is employed. It has been estimated that 18 million persons are affected, with 200,000 new cases each year. An increasing number of cases are found in the United States as patients migrate from endemic areas; in rare cases, it has been transmitted by transfusion and organ donation. After a quiescent, asymptomatic period, the so-called indeterminate phase, approximately one-third of infected persons develop chronic myocardial damage. A combination of infection by the parasite as well as autoimmune reactions are responsible for the cardiac manifestations. This condition, which is more frequent in males, is characterized by dilatation of several cardiac chambers, fibrosis and thinning of the ventricular wall, aneurysm formation in the left ventricle. Ventricular arrhythmias are common and are seen on Holter monitoring, especially during and after exertion. Medical therapy is often unsatisfactory or unavailable (especially in poor rural areas); however, a more promising tactic in endemic areas is the use of insecticides to eliminate the vector. It occurs most commonly in children and young adults residing in tropical and subtropical Africa, particularly Uganda and Nigeria, as well as in tropical Asia and South America. It is related and similar to hypereosinophilic endomyocardial disease (see earlier), although the eosinophilia is less severe and the course more chronic in endomyocardial fibrosis. The condition is characterized by severe fibrosis of the endocardium, with involvement of the inflow portion of the right or left ventricle (or both). The apex of the ventricles may be obliterated by a mass of thrombus and fibrous tissue. Multiple left ventricular aneurysms are noted in inferobasal, anterior, and inferior aspects of left ventricle (circled). Peripartum cardiomyopathy is far more common in Africa than in North America or Europe; the incidence has been reported to be especially high in Nigeria. Pathogenetic factors that may be operative include low socioeconomic status, high parity, prolonged lactation, excessive dietary salt intake, and selenium deficiency. J Am Coll Cardiol 42:1688, 2003 - et al: Contemporary definitions and classification of the cardiomyopathies: An American Heart Association Scientific Statement. However, thiamine deficiency in the West may occur in patients with severe alcoholism. So-called wet beri-beri heart disease is an important clinical manifestation of serious thiamine deficiency. It is characterized by cardiac failure secondary to a high cardiac output state caused by arteriolar vasodilation; it is associated with tachycardia, wide pulse pressure, a third heart sound, and warm extremities. The response to thiamine is usually dramatic, but it should be accompanied by diuretics. The normal pericardium, by exerting a restraining force, prevents sudden dilation of the cardiac chambers, especially of the right atrium and ventricle, during exercise and with hypervolemia. Notwithstanding the foregoing, total absence of the pericardium, either congenital or following surgery, does not produce obvious clinical disease. In partial left pericardial defects, the main pulmonary artery and left atrium may bulge through the defect; very rarely, herniation and subsequent strangulation of the left atrium may cause sudden death. Pain, a pericardial friction rub, electrocardiographic changes, and pericardial effusion with cardiac tamponade and paradoxical pulse are cardinal manifestations of many forms of acute pericarditis. Chest pain is an important but not invariable symptom in various forms of acute pericarditis (Chap. Characteristically, however, pericardial pain may be relieved by sitting up and leaning forward and is intensified by lying supine. Posttraumatic a this dissociation is useful in the differentiation between 255 these conditions. The pericardial friction rub, audible in about 85% of patients, may have up to three components per cardiac cycle, is high-pitched, and is described as rasping, scratching, or grating (Chap. The rub is often inconstant, and the loud to-and-fro leathery sound may disappear within a few hours, possibly to reappear on the following day. A pericardial rub is heard throughout the respiratory cycle, while a pleural rub disappears when respiration is suspended. Pericardial effusion is especially important clinically when it develops within a relatively short time as it may lead to cardiac tamponade (see later). Differentiation from cardiac enlargement may be difficult on physical examination, but heart sounds may be fainter with pericardial An autosomal recessive syndrome, characterized by growth failure, muscle hypotonia, hepatomegaly, ocular changes, enlarged cerebral ventricles, mental retardation, ventricular hypertrophy, and chronic constrictive pericarditis. The friction rub may disappear, and the apex impulse may vanish, but sometimes it remains palpable, albeit medial to the left border of cardiac dullness. The chest roentgenogram may show a "water bottle" configuration of the cardiac silhouette. Note that the right atrial wall is indented inward and its curvature is frankly reversed (arrow), implying elevated intrapericardial pressure above right atrial pressure. When severe, the extent of this motion alternates and may be associated with electrical alternans. The three most common causes of tamponade are neoplastic disease, idiopathic pericarditis, and pericardial effusion secondary to renal failure. Tamponade may also result from bleeding into the pericar- 257 dial space either following cardiac operations and trauma (including cardiac perforation during cardiac catheterization, percutaneous coronary intervention, or insertion of pacemaker wires) or from tuberculosis and hemopericardium. The quantity of fluid necessary to produce this critical state may be as little as 200 mL when the fluid develops rapidly or >2000 mL in slowly developing effusions when the pericardium has had the opportunity to stretch and adapt to an increasing volume. The volume of fluid required to produce tamponade also varies directly with the thickness of the ventricular myocardium and inversely with the thickness of the parietal pericardium. Tamponade may also develop more slowly, and under these circumstances the clinical manifestations may resemble those of heart failure, including dyspnea, orthopnea, and hepatic engorgement. A high index of suspicion for cardiac tamponade is required since, in many instances, no obvious cause for pericardial disease is apparent, and it should be considered in any patient with hypotension and elevation of jugular venous pressure. Table 22-2 lists the features that distinguish acute cardiac tamponade from constrictive pericarditis. Thus, in cardiac tamponade the normal inspiratory augmentation of right ventricular volume causes an exaggerated reciprocal reduction in left ventricular volume. Paradoxical pulse occurs not only in cardiac tamponade but also in approximately one-third of patients with constrictive pericarditis (see later). This physical finding is not pathognomonic of pericardial disease because it may be observed in some cases of hypovolemic shock, acute and chronic obstructive airways disease, and pulmonary embolus. Low-pressure tamponade refers to mild tamponade in which the intrapericardial pressure is increased from its slightly subatmospheric levels from +5 to +10 mmHg; in some instances, hypovolemia coexists. As a consequence, the central venous pressure is normal or only slightly elevated, while arterial pressure is unaffected and there is no paradoxical pulse. The diagnosis is aided by echocardiography, and both hemodynamic and clinical manifestations improve following pericardiocentesis. Diagnosis Since immediate treatment of cardiac tamponade may be lifesaving, prompt measures to establish the diagnosis by echocardiography should be undertaken. When pericardial effusion causes tamponade, Doppler ultrasound shows that tricuspid and pulmonic valve flow velocities increase markedly during inspiration, while pulmonic vein, mitral, and aortic flow velocities diminish. Often the right ventricular cavity is reduced in diameter, and there is late diastolic inward motion (collapse) of the right ventricular free wall and of the right atrium. Arterial and venous pressures and heart rate should be monitored or followed carefully and serial echocardiograms obtained. A small, multiholed catheter advanced over the needle inserted into the pericardial cavity may be left in place to allow draining of the pericardial space if fluid reaccumulates. Pericardial fluid obtained from an effusion often has the physical characteristics of an exudate. The pericardial fluid should be analyzed for red and white blood cells, and cytologic studies for cancer, microscopic studies, and cultures should be obtained. Commonly, there is an antecedent infection of 259 the respiratory tract, but in many patients such an association is not evident, and viral isolation and serologic studies are negative. Most frequently, a viral causation cannot be established; the term idiopathic acute pericarditis is then appropriate. Recurrent (relapsing) pericarditis occurs in about one-fourth of patients with acute idiopathic pericarditis. In many instances, acute pericarditis occurs in association with illnesses of known viral origin and, presumably, are caused by the same Hyperimmune globulin has been reported to be beneficial in cytomegalovirus, adenovirus, and parvovirus pericarditis, while interferon has been reported to be so in coxsackie B pericarditis. Anticoagulants should be avoided since their use could cause bleeding into the pericardial cavity and tamponade. Post-cardiac Injury Syndrome Acute pericarditis may appear under a variety of circumstances that have one common feature: previous injury to the myocardium with blood in the pericardial cavity. The syndrome may develop after a cardiac surgery (postpericardiotomy syndrome); after cardiac trauma, blunt or penetrating (Chap. The pericarditis may be of the fibrinous variety or it may be a pericardial effusion, which is often serosanguineous, but rarely causes tamponade. Leukocytosis, an increased sedimentation rate, and electrocardiographic changes typical of acute pericarditis may also occur. Circulating myocardial antisarcolemmal and antifibrillar autoantibodies occur frequently, but their precise role has not been defined. Viral infection may also play an etiologic role, since antiviral antibodies are often elevated in patients who develop this syndrome following cardiac surgery. It is important to distinguish pericarditis due to collagen vascular disease from acute idiopathic pericarditis. Acute pericarditis is an occasional complication of rheumatoid arthritis, scleroderma, and polyarteritis nodosa, and other evidence of these diseases is usually obvious. The pericarditis of acute rheumatic fever is generally associated with evidence of severe pancarditis and with cardiac murmurs (Chap. Pyogenic (purulent) pericarditis is usually secondary to cardiothoracic operations, by extension of infection from the lungs or pleural cavities, from rupture of the esophagus into the pericardial sac, or rupture of a ring abscess in a patient with infective endocarditis, or can occur if septicemia complicates aseptic pericarditis. It is accompanied by fever, chills, septicemia, and evidence of infection elsewhere and generally has a poor prognosis. Pericarditis of renal failure occurs in up to one-third of patients with chronic uremia (uremic pericarditis), is also seen in patients undergoing chronic dialysis with normal levels of blood urea and creatinine, and is termed dialysisassociated pericarditis. When the pericarditis of renal failure is recurrent or persistent, a pericardial window should be created or pericardiectomy may be necessary. The latter gradually contracts and forms a firm scar, encasing the heart and interfering with filling of the ventricles. In many patients the cause of the pericardial disease is undetermined, and in them an asymptomatic or forgotten bout of viral pericarditis, acute or idiopathic, may have been the inciting event. The basic physiologic abnormality in patients with chronic constrictive pericarditis is the inability of the ventricles to fill because of the limitations imposed by the rigid, thickened pericardium or the tense pericardial fluid. In constrictive pericarditis, ventricular filling is unimpeded during early diastole but it is reduced abruptly when the elastic limit of the pericardium is reached, while in cardiac tamponade, ventricular filling is impeded throughout diastole. Despite these hemodynamic changes, myocardial function may be normal or only slightly impaired in chronic constrictive pericarditis. However, the fibrotic process may extend into the myocardium and cause myocardial scarring, and atrophy, and venous congestion may then be due to the combined effects of the pericardial and myocardial lesions. In constrictive pericarditis, the right and left atrial pressure pulses display an M-shaped contour, with prominent x and y descents; the y descent, which is absent or diminished in cardiac tamponade, is the most prominent deflection in constrictive pericarditis; it reflects rapid early filling of the ventricles. They may cause few symptoms per se, and their presence may be detected by finding an enlarged cardiac silhouette on chest roentgenogram. Grossly sanguineous pericardial fluid results most commonly from a neoplasm, tuberculosis, renal failure, or slow leakage from an aortic aneurysm. Pericardiocentesis may resolve large effusions, but pericardiectomy may be required with recurrence. These hemodynamic changes, although characteristic, are not pathognomonic of constrictive pericarditis and may also be observed in cardiomyopathies characterized by restriction of ventricular filling (Chap.

This may be combined with a biceps tenodesis bacteria evolution discount sumycin 500 mg on line, in which the proximal biceps tendon is implanted into the humerus antibiotic metronidazole order sumycin 500 mg online, excising the intra-articular portion antibiotic gel buy sumycin 250mg without a prescription. Imaging Plain X-rays may show evidence of associated rotator cuff pathology which is similar to that of the impingement syndrome antibiotics keflex 500mg order sumycin cheap online. An ultrasound scan is used to assess the status of the rotator cuff and any associated rotator cuff tears virus and fever buy 250mg sumycin with mastercard. Operative intervention with an arthroscopic or open acromioclavicular joint excision treatment for vre uti cheapest sumycin, which involves resection of the lateral end of the clavicle, can be undertaken if conservative measures fail. Reconstructive surgery If the acromioclavicular joint is unstable, often secondary to trauma with rupture of the coracoclavicular ligaments, it can be stabilized by transferring other ligaments such as the coraco-acromial ligament or by inserting an artificial woven ligament, or by screw fixation of the clavicle to the coracoid. The synovitis causes rupture of the rotator cuff with secondary cartilaginous change which can lead to superior migration of the head of the humerus and the development of a rotator cuff arthropathy. Surgical intervention includes arthroscopic clearing of the synovium and washout of the joint to try to alleviate symptoms. A hemiarthroplasty can relieve pain if the above measures fail but may not improve function if the rotator cuff tendons are affected. Shoulder instability 179 converting the head of the humerus to a socket (reversing the joint) so that the deltoid muscle can take over the role of the rotator cuff. It has virtually no intrinsic bony stability and, therefore, the stability is provided by static and dynamic restraints. The static stabilizers consist of the glenoid labrum and the capsular ligaments, while the dynamic stabilization is provided by the muscles, principally those of the rotator cuff. There are three major causes of instability: trauma hyperlaxity muscle patterning disorders. The direction of the instability may be anterior, posterior or multidirectional and episodes may be acute, chronic or recurrent. These patients often benefit from physiotherapy designed to improve scapulothoracic muscle stabilization, coordination and strengthening. It should be recognized, however, that in this age group the risk of an associated rotator cuff injury increases with advancing years. Investigation Clinical diagnostic indicators the patient presents with pain on the lateral aspect of the elbow, often aggravated by lifting objects, shaking hands and exercise, particularly when wielding a tennis racket. There are two main types of operative intervention: repair of the capsulolabral tear (Bankart lesion) open bone transport procedures (Laterjet/ Bristow) where bone is transported from the coracoid to fill the glenoid bone defect and reinforce the anterior inferior joint capsule. An ultrasound scan may show disruption of the tendon insertions with interstitial tears or neovascularization. Operative intervention may include arthroscopic labral repair and open surgical techniques. Management Rest followed by physiotherapy with stretching and strengthening of the extensor tendons should be the initial treatment. Surgical intervention can be undertaken if the symptoms are not relieved by the above management. Blood tests Routine blood investigations may be required to detect the presence of underlying causative conditions and exclude potential infection. Management Treatment is with anti-inflammatory medication and rest to generally allow the bursitis to settle. This complication which can represent a significantly greater problem for the patient than an uncomplicated bursa. Depending on their site within the joint they may limit extension, flexion, supination and pronation. Other forms of radiological investigation seldom provide further useful information. Management the symptoms are first treated with antiinflammatory medication and an alteration of daily activity. Management Loose bodies may be removed from the elbow joint through an arthroscope. It is uncommon as a primary disorder, more likely to occur as a sequel to a previous injury. In addition to swelling, pain and tenderness, the elbow becomes unstable because of the soft tissue involvement. Management During an attack of acute synovitis, the elbow should be rested and the patient given anti-inflammatory drugs. Disease-modifying drugs have significantly reduced the incidence of rheumatoid disease. Imaging Plain X-rays should be used to detect any osteophyte formation in the region of the cubital tunnel or nearby degenerative joint disease. This usually occurs following a traumatic incident when the elbow is flexed against resistance. Management Treatment includes extension splinting at night and the avoidance of repetitive elbow movement. If these measures fail to resolve the problem, ulnar nerve decompression and/or transposition of the nerve to the anterior aspect of the elbow will relieve the symptoms, but nerve function does not always recover completely. Management the pain and swelling usually settle but, in the longer term, the biceps will ultimately atroph and patients experience a loss of approximately 50 per cent supination and 30 per cent flexion. Investigation Clinical diagnostic indicators Compression of the nerve results in pain, altered sensation and eventually, muscle denervation. Blood tests Blood investigations may be needed to elicit or exclude a precipitating cause such as rheumatoid arthritis, diabetes, myxoedema and pregnancy. Imaging Plain X-ray and other radiological imaging seldom reveal a significant abnormality. These tendons pass beneath a tight fibrous bridge just proximal to the styloid process of the radius. Investigation Clinical diagnostic indicators the patient develops a firm tender swelling on the radial aspect of the wrist which is often considered to be a bony outgrowth. The pain is caused by the un-united fracture and secondary changes in the radiocarpal joint and between the scaphoid and the neighbouring small bones of the hands. Imaging Plain X-rays will confirm non-union and show secondary changes consistent with avascular necrosis and bone degeneration. Investigation Clinical diagnostic indicators the pain it causes is centred over the carpometacarpal joint at the base of the thumb approximately 1 cm distal to the radial styloid process. Investigation Clinical diagnostic indicators the patient complains of aching and stiffness with tenderness localized to the centre of the dorsum of the wrist. Management Splintage, hand therapy and non-steroidal antiinflammatory agents can be used in the initial management. If this fails to control symptoms, then corticosteroid injection into the joint can be undertaken. As the disease progresses, removal of the lunate together with the proximal row of carpal bones (lunate, scaphoid and triquetrum) may be required. Persistent synovitis and progressive bony change may require synovectomy, repair of ruptured tendons, excision of the distal ulna, arthroplasty or arthrodesis. As the disease progresses the small joints are destroyed and tendon erosions lead to instability and progressive fixed deformity. X-rays initially show periarticular osteoporosis leading to periarticular erosion and joint space narrowing. Management Initial treatment is non-operative with resting splints, hand therapy and drugs but although this may relieve the symptoms it does not control the local disease. Imaging X-rays show periarticular osteoporosis, destructive osteolysis and arthritis of the distal radioulnar joint. Incision of the flexor tendon sheath to allow free passage of the tendon along its sheath is most effective. No specific investigation is warranted other than those needed to elicit the presence of associated co-morbidities. After surgery the hand is splinted and followed by hand therapy to maintain the operative correction. An improvement of any accompanying fixed flexion of the metacarpal-phalangeal joints is more likely than a reduction of any flexion deformity involving the interphalangeal joints. Appropriate antibiotics should be given, which, depending on the severity of the infection, may need to be given intravenously. It is surrounded by a tough membranous capsule lined by synovium and contains the synovial fluid that lubricates the joint. The numerous muscles and tendons between the pelvic bones and the greater and lesser trochanters of the femur assist in movements of the hip. They present with pain over the greater trochanter when they lie down and worsening pain on walking and climbing stairs. The pain can be reproduced on examination by deep palpation and by resisted abduction. Clinical diagnostic indicators Adductor tendonitis is most common in athletes, particularly horse riders. The following are the three most common causes of soft tissue pain around the hip. Management A combination of rest, massage and simple analgesia should be advised as first-line treatment, combined as the acute symptoms settle with gentle mobilization and stretching exercises. If conservative treatment fails, an injection with local anaesthetic and cortisone, preferably under ultrasound guidance, will usually help. A clunking or a snapping sensation may occur as the iliotibial band passes over the greater trochanter, Investigation Early diagnosis is crucial to prevent the development of irreversible changes which will lead to pain and deformity. As the disease progresses, the femoral head fragments and the bony anatomy becomes more distorted. This can be achieved by: avoidance of weight-bearing, and non-steroidal analgesia for the young patient with early changes braces or splints in older patients with more advanced disease. The diagnosis is reached by excluding other pathologies such as sepsis and hence routine blood investigations and plain X-rays should be performed. Treatment is symptomatic with bed rest, or a period of non-weight-bearing on crutches, and anti-inflammatory medication. Although the femoral head remains in the acetabulum, the neck of the femur displaces anteriorly and externally rotates. Management Surgical treatment, varied according to the degree of displacement, is essential. Continued surveillance is essential as the epiphysis may become avascular if the blood supply does not recover adequately. Investigation Clinical diagnostic indicators Pain and the effects of restriction of movement are the common symptoms and signs. Management Conservative treatment consists of initial symptom modifying activities, simple analgesics and walking aids. If there is a leg length discrepancy, a shoe raise may be employed to help balance the pelvis and relieve strains across the pelvis and lower back. Most implants comprise a femoral component made of either stainless steel or chrome cobalt molybdenum alloy, although ceramic heads of aluminium oxide are also used. Arthroscopy of the hip is also now being incorporated into orthopaedic practice and this may provide an avenue for future treatment. The patient will have marked pain, be unable to bear weight on the limb, and have a significantly reduced range of movement. An ultrasound-guided aspiration of the joint should be undertaken with samples sent for microscopic assessment and culture. Once the samples have been taken, intravenous antibiotics should be commenced, the antibiotic choice being governed by the sensitivity of the organism. The patellofemoral complex is essential in both stabilization and controlling extension and flexion. Surgical repair is the treatment of choice followed by a period of immobilization in a splint and then gradual rehabilitation to strengthen the tendon and restore muscle bulk. When the patellar tendon is affected the patient feels pain at the inferior pole of the patella. If the problem becomes chronic, steroid injection and surgical debridement may be beneficial. Management Arthroscopic resection of the plica is appropriate if pain is a significant clinical problem. They are vital for the stability of the knee joint and are frequently injured in sporting activities. Examination may reveal abnormal posterior movement and hyperextension of the joint. It attaches to the posterior horn of the lateral meniscus and prevents posterior translation of the tibia on the femur and hyperextension of the knee. The lateral meniscus is smaller and more mobile than the medial meniscus, with the popliteus muscle attached posteriorly.

Diseases

• Encephalotrigeminal angiomatosis
• Glycogen storage disease type 9
• Condyloma acuminatum
• N syndrome
• Restless legs syndrome
• Spherophakia brachymorphia syndrome

The cavity is drained and antibiotics for acne that won't affect birth control discount generic sumycin uk, if deep antibiotic resistance gene database buy sumycin without a prescription, packed to keep it open to allow healing from below upwards antibiotics pros and cons buy sumycin with american express. The pack needs to be changed daily until the wound has healed by secondary intention infection vs intoxication buy 500 mg sumycin with visa. Investigation A microbiology swab taken from the wall of the sinus and any discharge should be sent for microscopy bacteria nucleus generic 500mg sumycin amex, culture and sensitivity antibiotic used for pink eye sumycin 500mg visa. Surgical drainage of deep infection Lipoma 101 and excision of the sinus tract removes epithelium and foreign bodies allowing healing by secondary intention. Investigation Bacteriology A microbiology swab taken from the wall of the fistula and any discharge should be sent for microscopy, culture and sensitivity to exclude tuberculosis. Investigation Clinical diagnostic indicators They are usually solitary and found in the subcutaneous tissues and, less commonly, in internal organs. Typically, they develop as discrete rubbery masses in the subcutaneous tissues of the trunk and proximal extremity. Management Careful preoperative assessment is required to determine whether the lipoma is supra-, intra- or submuscular as this will determine whether the procedure should be performed under local or general anaesthesia. When a ganglion is in proximity to the radial artery, care must be taken to avoid damaging this structure as well as the palmar cutaneous branch of the median nerve. Surgical excision should be performed under regional or general anaesthesia with an arm tourniquet. In onychocryptosis, the primary direction of nail growth is lateral instead of forward. The laterally curved edge of the nail plate penetrates the lateral nail fold resulting in inflammation and pain. Investigation Clinical diagnostic indicators the infectious process begins in the lateral perionychium and is followed by the development of erythema, intense inflammation, swelling, pain and Management Medical care the foot should be washed regularly with soap and water and kept dry during the rest of the day. Investigation They have to be differentiated from ingrowing toenails and paronychia. Management the exostosis can be approached and excised either through a fish mouth incision leaving the nail plate in place or, after partial nail avulsion, through a longitudinal incision in the nail bed. Investigation Clinical diagnostic indicators the exostosis begins as a small elevation on the dorsal surface of the terminal phalanx but with time it may appear as an outgrowth under the distal nail edge, or it may even completely destroy the nail plate. Microbiology Microscopy and culture should be obtained of either clippings of the nail plate or a sample taken from the proximal nail where the concentration of hyphae is greatest. Management A combination of oral, topical and surgical therapy can increase efficacy. Topical antifungals are beneficial only for mild cases involving the very distal nail plate. Flame burns Scald burns Electrical burns Extinguish flames safely Remove hot charred clothes. It is occasionally mistaken for a fungal infection of the nail and mistreated with antifungal therapy. Cooling the surface reduces the inflammatory reaction and stops the progression of burn depth as well as acting as an analgesic. These are simple to use and allow wound inspection so that definitive assessment can be performed. Do not use tight dressings as this can constrict the limbs and compromise circulation. At least 250 000 others attend their general practitioner for treatment of their injury. In bigger burns, several layers of dressing are usually required to absorb exudate and to prevent shear or friction of the skin. Ensure inline immobilization of the cervical spine, avoiding hyperflexion or extension of the neck. Monitor the adequacy of resuscitation from: the urine output (urinary catheter): 0. Pain relief with morphine should be given only intravenously slowly and cautiously in small incremental doses until the pain is controlled. Examination the patient should be thoroughly examined from head to toe and any additional radiological investigations carried out where indicated. Accurate assessment of burn depth is vital as it differentiates between burns that will heal spontaneously and those that require surgical intervention (Table 5. Heart failure this can result from circulating myocardial depressant factors and myocardial oedema. Inotropic drugs should not be used in management until adequate fluid resuscitation has been ensured. Infection this is responsible for up to 75 per cent mortality in burns after the initial resuscitation. Renal failure this can arise early on as a result of delayed or inadequate fluid resuscitation or from substantial muscle breakdown or haemolysis. Treatment: systemic antibiotics excision of necrotic and infective tissue and cover Cerebral failure this can arise as a result of hypoxia, head injury or cerebral oedema from excessive fluid resuscitation. Close attention to nutritional needs is critical to prevent protein breakdown, decreased wound Healing occurs within two weeks. Antimicrobial agents are added where infection is likely (perineum and feet), heavy colonization is evident or invasive infection is suspected. Full-thickness burns acellular: allograft (glycerol preserved), alloderm and xenograft (porcine) cellular: allograft (cryopreserved), cultured keratinocytes, transcyte and dermagraft. Unless they are very small so that healing can occur from the edges, they will take weeks to heal and undergo severe contraction. Fascial excision is a faster technique with less blood loss, but more tissue is removed resulting in poorer function and cosmesis. Split skin graft (autograft) Desirable procedures Sheet grafts provide a superior cosmetic and functional result. Movement and function should be passive and active with the assistance of physiotherapy and occupational therapy. Scar management involves massage, silicone gel sheets, elastomer moulds, compression garments, sun protection, ultrasound and intralesional steroids. The psychological needs of the burn patient differ at each stage and require the involvement of social workers, vocational counsellors and psychologists. These are catastrophic injuries that cause extensive tissue damage and often rhabdomyolysis and subsequent renal failure. Lightning these injuries result from an ultra-high tension, high amperage, short duration electrical discharge of direct current. Important points to remember when dealing with electric burns are summarized in Table 5. Hydrofluoric acid penetrates tissues deeply and can cause fatal systemic toxicity even in small burns. They should be treated immediately with copious lavage and topical calcium gluconate gel. Military and police force injuries mainly occur as a consequence of war and civil unrest and are usually caused by missiles, gunshot, shrapnel, glass and burns (the management of burns is covered in Chapter 5). Most injuries are first seen at the site where they occur and then later, often by a different group of doctors, in a hospital Accident and Emergency Department (A&E). Assess the cause and extent of the injury/accident It has to be recognized that initial estimates of the number of casualties are often inaccurate because of confused communications and the shock experienced at the scene of the disaster by many of those involved, including the eye witnesses. In any major catastrophe, some are killed outright and many have relatively minor injuries, leaving a small group of patients in whom early appropriate intervention can save life and sometimes achieve a satisfactory outcome with no permanent sequelae. Exsanguinating bleeding should be stopped whenever possible by direct digital pressure or in military casualties the application of a tourniquet applied by a buddy. There is no point in breathing if there is no blood in the blood vessels to oxygenate, so catastrophic, exsanguinating bleeding must be dealt with first. The airway and breathing can be assumed to be satisfactory if the patient can speak, but extreme agitation may indicate the onset of hypoxia, which can lead to rapid unconsciousness and death if not correctly managed. Vomit and blood runs to the back of the throat and can only be removed with a sucker. The chin and jaw should then be lifted to prevent the tongue from falling back and occluding the airway. An endotracheal tube is required if breathing is not restored or the patient remains deeply unconscious with an absent gag reflex. Alternatives include the insertion of a laryngeal mask, a needle cricothyroidostomy or a tracheostomy, all of which can be life-saving in certain circumstances. Breathing Once an open airway has been established, breathing can be taken over by a bag valve mask or by direct connection to the tube. There are two schools of thought on the subsequent management of fluid replacement in patients presenting with hypovolaemic shock. It was originally thought that fluid administration should continue to maintain the blood pressure at a satisfactory level, i. The other school of thought, perhaps influenced by the management of leaking abdominal aortic aneurysms, holds that permissible, controlled hypotension, i. This approach reduces the risk of entering the vicious circle of raising the blood pressure, restarting bleeding and having to give further transfusions. It may also avoid the marked reduction of mesenteric and renal perfusion, which is the normal homeostatic response to hypovolaemic shock. Animal experiments suggest that the rapid restoration of blood volume results in a lower mortality, but it is difficult to translate the results of such studies to injured human beings. Analgesia and prophylactic antibiotics should be given if available, especially if the wounds are extensive and heavily contaminated. Helicopter air ambulances have become popular in many parts of the world where long distances are involved or roads are congested with traffic. They have their own inherent difficulties, which include inadequate landing sites and poor access to the patient during transfer. The hospital telephone exchange has the responsibility of contacting and requesting all the key personnel to assemble at the A&E. All members of the team must be clearly identified by an appropriate tabard (a labelled overall or tunic). He/she should have the ability to contact the operating theatres, the blood bank, intensive care and the wards in order to arrange the transfer of major casualties out of A&E as soon as they have been assessed and resuscitated. The junior members of the team should concentrate on ensuring an adequate airway and ventilation and obtaining access to the circulation. It is also helpful if some surgeons go directly to the operating theatres to help staff prepare for the amputations, laparotomies, fracture fixations and thoracotomies that may be required. C is for catastrophic haemorrhage this must be con- A sucking wound should be occluded. A simple hollow needle or other hollow device may be used as an alternative to deflate a life-threatening tension pneumothorax. A suspected haemothorax should be treated, initially, by inserting a chest drain through the tenth posterior intercostal space (air rises, fluid falls! Cardiac tamponade is one of the most difficult clinical diagnoses to make but should be suspected if there are congested neck veins, muffled heart sounds and occasionally the presence of pulsus paradoxus. It should be treated by needle aspiration of the pericardial sac using ultrasound guidance. If the patient is breathing spontaneously, has a good colour and is talking no further action needs to be taken. Physical examination of the chest helped by a chest have had intravenous catheters inserted before they reach hospital but, if this has not occurred, two large-bore needles or catheters should be inserted into the antecubital veins of both arms. A long saphenous vein cut-down or bone marrow infusion can be life-saving if these approaches fail. Blood should be sent for blood grouping and if a transfusion is likely to be needed, cross-matching. A urethral catheter should be passed provided there is no evidence of a urethral or bladder injury, when a suprapubic catheter is preferred. The history A more detailed history should be taken from the patient, if conscious, focusing on their recollection of the accident. Any obvious symptoms of pain, loss of function or loss of consciousness should be recorded. Any known past medical history, drug allergies and sensitivities should be documented.

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