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Apophyseal Injury

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141. Paraspinal Injections: Facet Joint and Nerve Root Blocks

injury to the vertebral artery, direct the needle into the posterior portion of the foramen. Do not advance the needle beyond the outer portion of the foramen; in fact, the needle can be placed outside the foramen with similar efficacy and less risk. The injection of contrast medium is critical to outline the nerve root (see image below). Contrast should never fill vessels, and it does not normally fill the subarachnoid space. The total volume of the local anesthetic and steroid should be smaller (...) injury from the needle tip. Regardless of the cause, in this author's opinion, contrast injection is recommended to at least potentially reduce the risk of intravascular injection, especially given the necessity, in today's environment, of practicing somewhat defensively. Spinal anesthesia may occur if local anesthetic is inadvertently injected into the nerve root sleeve. Prompt recognition of this potentially disastrous complication is vital during cervical procedures, because the patient's

2014 eMedicine Radiology

142. Rheumatoid Arthritis, Spine

border of the body of C7. A CHI of less than 2 mm is a sensitive predictor of neurologic deficit. These plain radiographic measurements, along with dynamic flexion-extension views provide a reliable and efficient means of assessing spinal involvement of rheumatoid disease and targeting at-risk patients, as well as selecting those who warrant further radiologic studies with a view to surgical stabilization. Thoracic and lumbar spinal involvement RA changes in the apophyseal joints of the thoracic (...) (flexed position) MRIs be obtained in patients with RA in whom cervical subluxation is suspected when routine MRI findings in the neutral position are normal. [ ] Others recommend functional MRI as a preoperative examination. [ ] Pathologic series have suggested that cord atrophy in rheumatoid cervical myelopathy results from repeated traction injury as a result of compression, stretch, and movement as opposed to an inflammatory process per se. This is unsurprising considering that the atlantoaxial

2014 eMedicine Radiology

143. Fracture, Pelvic (Treatment)

and analgesics as needed. Do not place a urinary catheter until urethral injury has been ruled out or determined to be unlikely by physical examination or retrograde urethrography. Pelvic apophyseal avulsion fractures are generally managed conservatively with rest and ice, followed by incremental protected weight-bearing with crutches until symptoms improve. Afterwards, progression to light stretching and full weight-bearing can proceed as tolerated with eventual return to full sports participation once full (...) of the left hemipelvis and a characteristic sacral buckle fracture. Note the concomitant left sacroiliac joint diastasis. The lateral force vector continued across the pelvis to produce external rotation of the right hemipelvis and diastasis of the right sacroiliac joint. The combination of injuries resulted in a windswept pelvis. Pelvic apophyseal avulsion fracture of the ischial tuberosity due to contraction of the hamstring muscles. Courtesy of Wikipedia (https://de.wikipedia.org/wiki/Apophyse). of 5

2014 eMedicine Emergency Medicine

144. Osgood-Schlatter Disease (Treatment)

however both groups reported symptom relief with no adverse outcomes. [ ] Long-term immobilization is typically contraindicated, because it may result in increased knee stiffness in mild cases, thus predisposing the athlete to additional sports-related injuries. However, if a patient is noncompliant, the clinician may recommend immobilization in a knee brace for a minimum of 6 weeks. The brace should be removed daily, but only for stretching and strengthening exercises. Inform the patient to avoid (...) of the extensor mechanism. Open reduction and internal fixation (ORIF) usually is recommended, depending on the size and displacement of the fragment as well as the phase of apophyseal closure. Indications for surgery Occasionally, adults have a large ossicle and an overlying bursa, which may cause pain with kneeling. If so, treatment consists of excision of the bursa, ossicle, and any prominence. [ ] Contraindications for surgery The real question is whether or not surgery is ever indicated in the growing

2014 eMedicine Surgery

145. Medial Humeral Condyle Fracture (Treatment)

-term studies and does not appear to be a major issue with these fractures. Previous References Rockwood CA, Wilkins KE, Beaty JH. Apophyseal injuries of the distal humerus. Fractures in Children . 3rd ed. Philadelphia: Lippincott-Raven; 1996. 800-19. Behrman MJ, Shelton ML. Fracture of the medial condyle of the humerus in an elderly patient. J Orthop Trauma . 1990. 4(1):98-101. . Bensahel H, Csukonyi Z, Badelon O. Fractures of the medial condyle of the humerus in children. J Pediatr Orthop . 1986 (...) . . Karlsson MK, Herbertsson P, Nordqvist A, Besjakov J, Josefsson PO, Hasserius R. Comminuted fractures of the radial head. Acta Orthop . 2010 Apr. 81 (2):224-7. . Haxhija EQ, Mayr JM, Grechenig W. [Treatment of medial epicondylar apophyseal avulsion injury in children]. Oper Orthop Traumatol . 2006 Jun. 18(2):120-34. . Hoppenfeld S, Murthy VL. Treatment and Rehabilitation of Fractures . Philadelphia: Lippincott Williams & Wilkins; 2000. Media Gallery Schematic of two types of medial condyle fractures

2014 eMedicine Surgery

146. Idiopathic Scoliosis (Treatment)

of the nerve injury risks of sublaminar wires. Pedicle screws have also become a popular anchor for the rods used in posterior scoliosis fusion procedures. [ ] They offer the potential advantage of increased strength (and possibly power of correction) while at the same time introducing added insertion-technique complexity and different neurologic complication risks. A very real and major increase in the overall cost of instrumentation constructs that include many pedicle screws is the case when (...) are not often directly visualized during posterior surgical approaches for scoliosis, but they must not be forgotten. These muscles include the trapezius, the rhomboid major, the rhomboid minor, and the latissimus dorsi. Using an animal model, Kawaguchi et al showed that significant posterior muscle injury can be induced by the pressure exerted by surgical retractors. [ ] This certainly makes a case for intermittent removal and replacement of such retractors during the course of posterior spinal surgery

2014 eMedicine Surgery

147. Atlantoaxial Instability (Overview)

rotatory subluxation are shown in the image below. Shown are 4 types of atlantoaxial rotatory subluxation. Because the cervical spine has multiple synovial-lined articulations, RA can manifest itself in the upper cervical spine. [ , ] In a person with AAI, the rheumatoid process affects the articular cartilage of the apophyseal joints, even the type II articular cartilage in the transverse ligament. [ ] In addition, the rheumatoid pannus and the associated inflammation can weaken the transverse (...) for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery . 2013 Aug. 60 Suppl 1:82-91. . Haid RW Jr. C1-C2 transarticular screw fixation: technical aspects. Neurosurgery . 2001 Jul. 49(1):71-4. . Naseer R, Bailey SI. Atlantoaxial instability treated with transarticular screw fixation. Int Orthop . 2001. 25(4):268-71. . Henriques T, Cunningham BW, Olerud C, Shimamoto N, Lee GA, Larsson S, et al. Biomechanical comparison of five different atlantoaxial posterior fixation

2014 eMedicine Surgery

148. Ankylosing Spondylitis (Overview)

) and transforming growth factor-β (TGF-β), are also important in the inflammatory process by leading to fibrosis and ossification at sites of enthesitis. [ , , ] The initial presentation of AS generally relates to the SI joints; involvement of the SI joints is required to establish the diagnosis. SI joint involvement is followed by involvement of the discovertebral, apophyseal, costovertebral, and costotransverse joints and the paravertebral ligaments. Early lesions include subchondral granulation tissue (...) spondylitis. J Rheumatol . 1999 Apr. 26(4):971-4. . Anwar F, Al-Khayer A, Joseph G, Fraser MH, Jigajinni MV, Allan DB. Delayed presentation and diagnosis of cervical spine injuries in long-standing ankylosing spondylitis. Eur Spine J . 2011 Mar. 20(3):403-7. . . Baraliakos X, Hermann KG, Landewé R, Listing J, Golder W, Brandt J, et al. Assessment of acute spinal inflammation in patients with ankylosing spondylitis by magnetic resonance imaging: a comparison between contrast enhanced T1 and short tau

2014 eMedicine Surgery

149. Sever Disease (Treatment)

injuries of the foot and ankle in the child and adolescent athlete. Phys Med Rehabil Clin N Am . 2008 May. 19 (2):347-71, ix. . Weiner DS, Morscher M, Dicintio MS. Calcaneal apophysitis: simple diagnosis, simpler treatment. J Fam Pract . 2007 May. 56 (5):352-5. . Clemow C, Pope B, Woodall HE. Tools to speed your heel pain diagnosis. J Fam Pract . 2008 Nov. 57 (11):714-23. . Irving DB, Cook JL, Young MA, Menz HB. Impact of chronic plantar heel pain on health-related quality of life. J Am Podiatr Med (...) . Is radiographic evaluation necessary in children with a clinical diagnosis of calcaneal apophysitis (sever disease)?. J Pediatr Orthop . 2011 Jul-Aug. 31 (5):548-50. . Brenner JS, American Academy of Pediatrics Council on Sports Medicine and Fitness. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics . 2007 Jun. 119 (6):1242-5. . Wu M, Fallon R, Heyworth BE. Overuse Injuries in the Pediatric Population. Sports Med Arthrosc Rev . 2016 Dec. 24 (4):150-158. . Perhamre S

2014 eMedicine Surgery

150. Diaphyseal Femur Fractures (Treatment)

polytrauma patients) with these fractures. Surgery for diaphyseal femur fracture should be reserved for those able to tolerate the appropriate procedure for their circumstance. Young children can often be treated successfully with noninvasive measures; thus, surgery can be avoided. Definite indications include polytrauma patients, especially those with head and chest injuries, and those with injuries to multiple limbs or those otherwise unable to care for themselves to maximize postoperative independence (...) . Most others are surgical candidates because of the lower incidence of complication and the higher union rates with surgery. Those who should not be treated surgically include patients too unstable to tolerate the procedure and children weighing less than 80 lb. No one can argue with the high success rate of reamed locked antegrade nailing. However, patients with femoral-shaft fractures often present with a multitude of injuries including head and chest trauma. Laboratory studies have shown

2014 eMedicine Surgery

151. Growth Plate (Physeal) Fractures (Treatment)

cause significant genu recurvatum. The image below illustrates a procurvatum deformity of the proximal tibia after repair of a proximal tibia apophyseal avulsion. Growth plate (physeal) fractures. Procurvatum of proximal tibia after open reduction and internal fixation of proximal tibia apophysis injury. If the fracture is nondisplaced or an anatomic stable reduction can be obtained with closed manipulation, treatment consists of an above-knee cast for 4 weeks. Generally, displaced apophyseal (...) =aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTI2MDY2My10cmVhdG1lbnQ= processing > Growth Plate (Physeal) Fractures Treatment & Management Updated: Jul 13, 2017 Author: Steven I Rabin, MD; Chief Editor: Jeffrey D Thomson, MD Share Email Print Feedback Close Sections Sections Growth Plate (Physeal) Fractures Treatment Approach Considerations Salter-Harris (SH) I and SH II growth plate (physeal) injuries usually can be managed adequately with closed manipulative reduction. Upon reduction, these injuries are typically stable, and casting suffices. At times

2014 eMedicine Surgery

152. Growth Plate (Physeal) Fractures (Overview)

(Physeal) Fractures Updated: Jul 13, 2017 Author: Steven I Rabin, MD; Chief Editor: Jeffrey D Thomson, MD Share Email Print Feedback Close Sections Sections Growth Plate (Physeal) Fractures Overview Background Growth plate (physeal) fractures may be defined as disruptions in the cartilaginous physis of long bones that may or may not involve epiphyseal or metaphyseal bone. [ ] Injuries to the physes are more likely to occur in an active pediatric population than sprains or ligament injuries are, in part (...) be different in children as compared with adults; percutaneous Kirschner wire (K-wire) fixation may be stable enough, and prevention of iatrogenic injury to the physis is of significant importance. When growth deformity is possible, the treating provider must predict the degree of expected remodeling, and this requires an understanding of the specific fracture. Assessment of bone age using the Greulich-Pyle atlas and charts can give an estimate of remaining growth. Fractures in the metaphysis, closer

2014 eMedicine Surgery

153. Pelvic Fractures (Overview)

or with apophyseal avulsion fractures of the iliac wing or ischial tuberosity resulting from an athletic injury. Low-energy pelvic fractures in the elderly frequently result from falls while ambulating, which are highlighted by stable fractures of the pelvic ring. Elderly patients also may present with insufficiency fractures, typically of the and anterior pelvic ring. [ ] High-energy pelvic fractures most commonly occur after motor vehicle crashes. Other mechanisms of high-energy pelvic fractures include (...) : George V Russell Jr, MD; Chief Editor: William L Jaffe, MD Share Email Print Feedback Close Sections Sections Pelvic Fractures Overview Background Unstable pelvic fractures typically occur as a result of high-energy injuries. Associated organ system injuries are observed commonly with pelvic fractures because of the energy imparted to the patient. Head, chest, and abdominal injuries frequently occur in association with pelvic fractures. Fractures of the extremities and also can occur in patients

2014 eMedicine Surgery

154. K&ouml (Overview)hler Disease (Overview)

or secondary centers of ossification; almost all of the epiphyses, apophyses, and small bones can be implicated. [ ] In Köhler disease, AVN of the navicular bone occurs. The etiology of these conditions is not well known, but vascular accidents, coagulation anomalies, and heredity have been implicated. [ ] The most common osteochondroses are Kienbock, and Panner diseases. Surgery is not indicated for Köhler disease; treatment is nonoperative (see ). Next: Pathophysiology Vascularization of the navicular (...) ; this clinical entity has been rarely reported in the years since. Dharamsi and Carl reported a case of isolated bilateral Köhler disease of the patella in a male athlete aged approximately 7 years. [ ] Previous Next: Etiology The etiology of Köhler disease, like those of the other osteochondroses, is unknown, but the condition is thought to result from compressive stress-related injury at a critical time of growth. [ ] Vascular insults, retarded bone age, and genetic predilection have also been implicated

2014 eMedicine Surgery

155. Osteoarthritis (Overview)

in previously intact joints and having no apparent initiating factor. Some clinicians limit the term primary osteoarthritis to the joints of the hands (specifically, the DIP and PIP joints and the joints at the base of the thumb). Others include the knees, hips, and spine (apophyseal articulations) as well. As underlying causes of osteoarthritis are discovered, the term primary, or idiopathic, osteoarthritis may become obsolete. For instance, many investigators believe that most cases of primary (...) , obesity may be an inflammatory risk factor for osteoarthritis. Obesity is associated with increased levels (both systemic and intra-articular) of adipokines (cytokines derived from adipose tissue), which may promote chronic, low-grade inflammation in joints. [ ] Other causes Trauma or surgery (including surgical repair of traumatic injury) involving the articular cartilage, ligaments, or menisci can lead to abnormal biomechanics in the joints and accelerate osteoarthritis. In individuals who have

2014 eMedicine Surgery

156. Osgood-Schlatter Disease (Overview)

traction (traction apophysitis) on the anterior portion of the developing ossification center leads to multiple subacute microavulsion fractures and/or tendinous inflammation, resulting in a benign, self-limited disturbance manifested as pain, swelling, and tenderness. The most common long-term ramifications of OSD are pain on kneeling as an adult and the cosmesis of a bony prominence on the anterior knee. Less common complications are the persistence of a painful ossicle requiring surgical excision (...) persist for 2-3 years until the tibial growth plate closes. Previous Next: Patient Education Inform patients about activities that aggravate Osgood-Schlatter disease and about the self-limiting nature of the condition. For patient education information, see the , the , and the , as well as . Previous References Pommering TL, Kluchurosky L. Overuse injuries in adolescents. Adolesc Med State Art Rev . 2007 May. 18(1):95-120, ix. . Smith JM, Varacallo M. Osgood Schlatter Disease. StatPearls [Internet

2014 eMedicine Surgery

157. Medial Humeral Condyle Fracture (Overview)

of injury for medial epicondyle fractures [ , ] have been proposed for an acute injury. All of them result in a partial or complete separation of the apophyseal fragment from the rest of the humerus. The first mechanism of injury is a direct blow on the posterior medial aspect of the epicondyle that may be associated with fragmentation of the avulsed bone. The second mechanism is a pure avulsion injury produced by the flexor muscles of the forearm (see the image below). This avulsion may occur (...) fractures appear to do worse if the epicondyle is excised than if they are treated nonsurgically. Previous References Rockwood CA, Wilkins KE, Beaty JH. Apophyseal injuries of the distal humerus. Fractures in Children . 3rd ed. Philadelphia: Lippincott-Raven; 1996. 800-19. Behrman MJ, Shelton ML. Fracture of the medial condyle of the humerus in an elderly patient. J Orthop Trauma . 1990. 4(1):98-101. . Bensahel H, Csukonyi Z, Badelon O. Fractures of the medial condyle of the humerus in children. J

2014 eMedicine Surgery

158. Lumbar Spine Fractures and Dislocations (Overview)

acute fractures are or vertebral endplate fractures caused by sudden axial loading, transverse process avulsion by the origin of the psoas muscle, spinous process avulsions, and acute fracture of the pars interarticularis from hyperextension. Vertebral body compression is more common in patients with decreased bone density. [ , ] In adolescents, it is relatively common to find endplate fractures or apophyseal avulsion fractures. All of these injuries generally are stable and heal with immobilization (...) > Lumbar Spine Fractures and Dislocations Updated: Oct 16, 2018 Author: Federico C Vinas, MD; Chief Editor: Jeffrey A Goldstein, MD Share Email Print Feedback Close Sections Sections Lumbar Spine Fractures and Dislocations Overview Background Each year, more than 150,000 persons in North America sustain fractures of the vertebral column. Injuries to the thoracolumbar and lumbar spine constitute most of these fractures. The immediate neurologic damage that accompanies the bony destruction results

2014 eMedicine Surgery

159. Kyphosis (Overview)

of Scheuermann disease is still imprecisely defined. Scheuermann postulated that the condition resulted from avascular necrosis of the apophyseal ring. Other theories include histologic abnormalities at the endplate, osteoporosis, [ ] and mechanical factors that affect spinal growth. [ ] A Danish study demonstrated an important genetic component to the entity. [ ] Postural kyphosis is present when accentuated kyphosis is observed without the characteristic 5° of wedging over three consecutive vertebral (...) , and one had a wound infection. No permanent neurologic injuries occurred. Video-assisted thoracoscopic release followed by posterior arthrodesis has been successful. In one study, deformity correction was 84.8° to 45.3° in patients with thoracic kyphosis associated with Scheuermann disease. [ ] Mean loss of correction was 1.6°, and one hook pulled out. No cases of junctional kyphosis were observed. In a retrospective study, anterior-posterior correction was compared with posterior-only instrumentation

2014 eMedicine Surgery

160. Osgood-Schlatter Disease (Follow-up)

however both groups reported symptom relief with no adverse outcomes. [ ] Long-term immobilization is typically contraindicated, because it may result in increased knee stiffness in mild cases, thus predisposing the athlete to additional sports-related injuries. However, if a patient is noncompliant, the clinician may recommend immobilization in a knee brace for a minimum of 6 weeks. The brace should be removed daily, but only for stretching and strengthening exercises. Inform the patient to avoid (...) of the extensor mechanism. Open reduction and internal fixation (ORIF) usually is recommended, depending on the size and displacement of the fragment as well as the phase of apophyseal closure. Indications for surgery Occasionally, adults have a large ossicle and an overlying bursa, which may cause pain with kneeling. If so, treatment consists of excision of the bursa, ossicle, and any prominence. [ ] Contraindications for surgery The real question is whether or not surgery is ever indicated in the growing

2014 eMedicine Surgery

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