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Apophyseal Injury

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141. Sickle Cell Anemia (Diagnosis)

by a spinal artery branch) results in the characteristic H vertebrae of sickle cell disease. The outer portions of the plates are spared because of the numerous apophyseal arteries. Osteonecrosis of the epiphysis of the femoral head is often bilateral and eventually progresses to collapse of the femoral heads. This same phenomenon is also seen in the humeral head, distal femur, and tibial condyles. Infarction of bone and bone marrow in patients with sickle cell disease can lead to the following changes (...) and an inability to deal with infective encapsulated microorganisms, particularly Streptococcus pneumoniae, ensue, leading to an increased risk of sepsis in the future. Chronic hemolytic anemia SCD is a form of hemolytic anemia, with red cell survival of around 10-20 days. Approximately one third of the hemolysis occurs intravascularly, releasing free hemoglobin (plasma free hemoglobin [PFH]) and arginase into plasma. PFH has been associated with endothelial injury including scavenging nitric oxide

2014 eMedicine Pediatrics

142. Sickle Cell Anemia (Overview)

by a spinal artery branch) results in the characteristic H vertebrae of sickle cell disease. The outer portions of the plates are spared because of the numerous apophyseal arteries. Osteonecrosis of the epiphysis of the femoral head is often bilateral and eventually progresses to collapse of the femoral heads. This same phenomenon is also seen in the humeral head, distal femur, and tibial condyles. Infarction of bone and bone marrow in patients with sickle cell disease can lead to the following changes (...) and an inability to deal with infective encapsulated microorganisms, particularly Streptococcus pneumoniae, ensue, leading to an increased risk of sepsis in the future. Chronic hemolytic anemia SCD is a form of hemolytic anemia, with red cell survival of around 10-20 days. Approximately one third of the hemolysis occurs intravascularly, releasing free hemoglobin (plasma free hemoglobin [PFH]) and arginase into plasma. PFH has been associated with endothelial injury including scavenging nitric oxide

2014 eMedicine Pediatrics

143. Fracture, Pelvic (Follow-up)

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 Emergency Medicine

145. Anemia, Sickle Cell (Overview)

by a spinal artery branch) results in the characteristic H vertebrae of sickle cell disease. The outer portions of the plates are spared because of the numerous apophyseal arteries. Osteonecrosis of the epiphysis of the femoral head is often bilateral and eventually progresses to collapse of the femoral heads. This same phenomenon is also seen in the humeral head, distal femur, and tibial condyles. Infarction of bone and bone marrow in patients with sickle cell disease can lead to the following changes (...) and an inability to deal with infective encapsulated microorganisms, particularly Streptococcus pneumoniae, ensue, leading to an increased risk of sepsis in the future. Chronic hemolytic anemia SCD is a form of hemolytic anemia, with red cell survival of around 10-20 days. Approximately one third of the hemolysis occurs intravascularly, releasing free hemoglobin (plasma free hemoglobin [PFH]) and arginase into plasma. PFH has been associated with endothelial injury including scavenging nitric oxide

2014 eMedicine Emergency Medicine

146. Disk Herniation

of annular fissure, herniation, and degeneration. [ ] Degeneration may include any or all of the following: real or apparent desiccation; fibrosis; narrowing of the disk space; diffuse bulging of the annulus beyond the disk space; extensive fissuring (eg, numerous annular tears) and mucinous degeneration of the annulus; intradiskal gas; defects and sclerosis of the endplates; and the occurrence of osteophytes at the vertebral apophyses. Annular Fissures Annular fissures are separations between (...) the nucleus peripherally to or through the annulus; and a transverse fissure is a horizontally oriented radial fissure. [ ] Herniation Herniation is defined as a localized or focal displacement of disk material beyond the limits of the intervertebral disk space. The disk material may be nucleus, cartilage, fragmented apophyseal bone, annular tissue, or any combination thereof. The endplates of the vertebral body define the disk space cranially and caudally; the outer edges of the vertebral ring apophyses

2014 eMedicine Radiology

147. Ankylosing Spondylitis

of a solid midline, vertical, dense line on frontal radiographs (see the image below). Interspinous ossification. Frontal radiograph shows T12-L2 lateral syndesmophytes and interspinous ligament ossification extending from the T12 to L1 and L2 to L4 levels. The apophyseal and costovertebral joints frequently are affected by erosions and eventually undergo fusion (see the image below). Vertebral fusion. Lateral radiograph shows solid ankylosis of all cervical facet joints from C2 downwards. Extensive (...) anterior and posterior syndesmophytes are noted. Complete fusion of the vertebral bodies by syndesmophytes and other related ossified areas produces bamboo spine (see the image below). Bamboo spine. Frontal radiograph shows complete fusion of the vertebral bodies. Extensive facet joint ankylosis and posterior ligamentous ossification produce the trolley track appearance. Calcifications of the disk may occur at single or multiple levels; they are usually associated with apophyseal joint ankylosis

2014 eMedicine Radiology

148. Pediatrics, Sickle Cell Disease (Diagnosis)

by a spinal artery branch) results in the characteristic H vertebrae of sickle cell disease. The outer portions of the plates are spared because of the numerous apophyseal arteries. Osteonecrosis of the epiphysis of the femoral head is often bilateral and eventually progresses to collapse of the femoral heads. This same phenomenon is also seen in the humeral head, distal femur, and tibial condyles. Infarction of bone and bone marrow in patients with sickle cell disease can lead to the following changes (...) and an inability to deal with infective encapsulated microorganisms, particularly Streptococcus pneumoniae, ensue, leading to an increased risk of sepsis in the future. Chronic hemolytic anemia SCD is a form of hemolytic anemia, with red cell survival of around 10-20 days. Approximately one third of the hemolysis occurs intravascularly, releasing free hemoglobin (plasma free hemoglobin [PFH]) and arginase into plasma. PFH has been associated with endothelial injury including scavenging nitric oxide

2014 eMedicine Emergency Medicine

149. Sickle Cell Anemia (Diagnosis)

by a spinal artery branch) results in the characteristic H vertebrae of sickle cell disease. The outer portions of the plates are spared because of the numerous apophyseal arteries. Osteonecrosis of the epiphysis of the femoral head is often bilateral and eventually progresses to collapse of the femoral heads. This same phenomenon is also seen in the humeral head, distal femur, and tibial condyles. Infarction of bone and bone marrow in patients with sickle cell disease can lead to the following changes (...) and an inability to deal with infective encapsulated microorganisms, particularly Streptococcus pneumoniae, ensue, leading to an increased risk of sepsis in the future. Chronic hemolytic anemia SCD is a form of hemolytic anemia, with red cell survival of around 10-20 days. Approximately one third of the hemolysis occurs intravascularly, releasing free hemoglobin (plasma free hemoglobin [PFH]) and arginase into plasma. PFH has been associated with endothelial injury including scavenging nitric oxide

2014 eMedicine.com

150. Osteoarthritis (Diagnosis)

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.com

151. Osgood-Schlatter Disease (Diagnosis)

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.com

152. The Approach to the Painful Joint (Diagnosis)

spine, ask the patient to touch the chin to the chest (flexion) and then look up at the ceiling (extension). For lateral flexion, ask the patient to touch an ear to the shoulder. For lateral rotation, ask the patient to touch the chin to a shoulder. During lateral rotation and flexion, pain that occurs on the ipsilateral side of the neck is bony in origin (eg, from apophyseal joint disease), whereas pain on the contralateral side is muscular or ligamentous in origin. With the thoracic spine (...) polyarthritis include the following: Traumatic osteoarthritis (see ) Hypertrophic pulmonary osteoarthropathy Amyloidosis (see ) Differential diagnoses for regional musculoskeletal pain Shoulder Referred pain may derive from cervical disorders, Pancoast tumor of the lung, subphrenic pathology, or entrapment neuropathies and brachial neuritis (see ). Rotator cuff tendinitis (see ) [ ] is inflammation of the rotator cuff tendons, arising acutely as a result of a recognizable injury (throwing) or insidiously

2014 eMedicine.com

153. Hip Tendonitis and Bursitis (Diagnosis)

pain, such as a hamstring tendinopathy from repetitive activities such as running. Training errors, biomechanical issues, and sudden increases in activity levels are also risk factors. In the adolescent age group, traction injuries such as avulsion fracture and apophysitis can occur and cause difficulties with training and performance. [ , ] The investigation into the cause and treatment of hip overuse injuries can often be frustrating for clinicians and patients alike. Many musculoskeletal (...) . Sports Med . 1998 Apr. 25(4):271-83. . Garrick JG, Webb DR. Sports Injuries: Diagnosis and Management . 2nd ed. Philadelphia, Pa: WB Saunders; 1999. Shbeeb MI, Matteson EL. Trochanteric bursitis (greater trochanter pain syndrome). Mayo Clin Proc . 1996 Jun. 71(6):565-9. . Kujala UM, Orava S, Karpakka J, Leppävuori J, Mattila K. Ischial tuberosity apophysitis and avulsion among athletes. Int J Sports Med . Feb 1997. 18(2):149-55. . Kivlan BR, Martin RL. Functional performance testing of the hip

2014 eMedicine.com

154. Elbow Trauma, Pediatric

right elbow (B) and a previous view of the left elbow obtained when the patient was 10 years of age (C). These injuries resemble Salter-Harris type I, III, and II fractures, respectively, though the Salter-Harris classification is usually applied to injuries of the epiphyses rather than those of the apophyses. For those injuries that include a small portion of the metaphysis, care must be taken to distinguish medial epicondyle fracture (usually an extraarticular injury) from medial condyle fracture (...) radiographs in the setting of acute trauma may be challenging for many emergency department physicians, orthopedic surgeons, and radiologists. Diagnostic difficulties stem both from the complex developmental anatomy of the elbow and from significant differences between children and adults in the patterns of injury after elbow trauma. [ , , , ] Standard radiographic evaluation of the elbow includes imaging in the anteroposterior (AP) and lateral views. Other views may also be helpful, such as the internal

2014 eMedicine Radiology

155. 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

156. 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

157. 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

158. 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

159. 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

160. 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

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