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Femoral Neck Stress Fracture

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321. Temporal (Giant Cell) Arteritis (Diagnosis)

may have a role (see ). One school of thought considers GCA and to be different manifestations of the same disease process, while others see them as closely related but different diseases. [ , ] Common signs and symptoms of GCA reflect the involvement of the temporal artery and other medium-sized arteries of the head and the neck and include visual disturbances, headache, jaw claudication, neck pain, and scalp tenderness. Constitutional manifestations, such as fatigue, malaise, and fever, may also (...) infarction (MI) Less often, the descending aorta and mesenteric, renal, iliac, and femoral arteries can be affected, with attendant complications of intestinal infarction, renal infarction, crural infarction, and ischemic mononeuropathies [ , ] Pulmonary arterial involvement has also been described Some veins may be affected occasionally The most common cause of vision loss in GCA is anterior ischemic optic neuropathy (AION). This results from ischemia of the optic nerve head, which is supplied mainly

2014 eMedicine.com

322. The Approach to the Painful Joint (Diagnosis)

of the synovium. Bacterial products released within the joint are capable of producing rapid cartilage destruction. Structural or mechanical joint derangement Degeneration of the articular cartilage is the principal pathologic feature of osteoarthritis. [ ] It occurs in response to both local and host factors. Local factors include the following: Previous joint trauma (eg, meniscal tears) Congenital or developmental joint alterations (eg, congenital hip dysplasia and slipped capital femoral epiphysis (...) in response to synovial inflammation, trauma, anasarca, intra-articular hemorrhage (hemarthrosis), or an adjacent focus of acute inflammation (sympathetic effusion). These are detected by performing fluid ballottement or cross-fluctuation through the synovial cavity. Pain throughout the whole range of motion is observed in a person with an acutely inflamed joint. Pain experienced as the joint is gently forced (ie, stressed) towards its limitation of range is suggestive of synovitis. Pain not present

2014 eMedicine.com

323. Urological Management in Neurological Disease (Diagnosis)

the spinal canal. Previous Next: Iatrogenic Voiding Dysfunction Whereas a painless atonic neurogenic or motor paralytic bladder can be caused by peripheral neuropathy of diabetes or alcoholism, it can also be the result of trauma or pelvic surgery. In rare cases, pudendal nerves are injured after orthopedic surgery for femoral fractures. Amarenco et al reported 6 cases of pudendal nerve traction after orthopedic surgery in which bladder function was not involved, but the patients did experience genital (...) after pelvic or spinal cord trauma and spinal stenosis potentially affecting the cauda equina or conus. Occasionally, needle EMG may be used to evaluate pelvic pain syndromes. EMG is usually not performed in cases of stress urinary incontinence or cases in which a central nervous system (CNS) lesion is producing the incontinence. Muscle fibers in the periurethral striated muscle are predominantly type Ia, the slow-twitch, fatigue-resistant fibers. The rhabdosphincter fibers are generally smaller

2014 eMedicine.com

324. Low Energy Availability in the Female Athlete (Diagnosis)

meals that are less energy dense may be an important means of avoiding low energy availability conditions and thus preventing the female athlete triad [ ] Musculoskeletal history A careful review of past and current musculoskeletal injuries in the female athlete should be conducted. There should be a focus on all stress fractures, as well as on other fractures. There is an increase in risk of stress fractures in females with a chronic energy deficit. Any injury that results in loss of training (...) history or physical examination suggests the presence of a , plain radiography should be the initial test of choice. A three-phase bone scan should be performed if the radiographs are negative. Dual-energy radiographic absorptiometry (DRA) can be used in athletes with multiple stress fractures. DRA scans can also be used to assess for osteopenia or osteoporosis. can be useful for determining the etiology of primary amenorrhea (eg, presence of ovaries, uterus). If abnormal pituitary function

2014 eMedicine.com

325. Overuse Injury (Diagnosis)

imaging studies. However, if surgical intervention is considered, imaging studies are vital for the decision-making process. Radiography is useful for defining bony avulsions, which are relatively common among people who participate in dance, athletic activity, and heavy physical labor. Stress fractures, calcification of tendons (which occurs in persons with chronic tendonitis), joint mice, myositis ossificans, heterotopic ossification, and atrophy of cartilage generally are revealed with radiography (...) . Bone scanning may reveal stress fractures that are not evident on radiographs. Typically, magnetic resonance imaging (MRI) is most effective for acute injuries; findings are generally more subtle with chronic injuries. MRI has been quite successful in revealing tendon, ligament, and muscle injuries. In cases of peripheral nerve compression or trauma, electrodiagnostic testing can provide evidence of the location and severity of the injury. In the hands of a skilled clinician, ultrasonography (US

2014 eMedicine.com

326. Shock and Pregnancy (Diagnosis)

to gestational age. A blood pressure measurement of 130/80 mm Hg may be normal at term but is abnormal at 28 weeks' gestation, when it should be approximately 110/60 mm Hg. The venous pressure in the legs increases progressively during pregnancy, caused by compression of the pelvic veins and inferior vena cava by the uterus. The elevated femoral venous pressure returns to a normal level following labor. The measurement of brachial artery pressure is not indicative of the uterine arterial blood pressure (...) , multiorgan failure, and death. The clinical signs of cardiogenic shock are distended neck veins, dyspnea, tachypnea, the presence of a third heart sound, systolic or diastolic murmurs, and generalized edema. Peripartum cardiomyopathy is an idiopathic disorder that occurs during the last month of pregnancy and up to 6 months postpartum. The incidence of this disease is 1 case in 1500-4000 deliveries. The risk factors include old age, multiparity, twin gestation, and preeclampsia. Upon presentation

2014 eMedicine.com

327. Osteoporosis (Secondary) (Diagnosis)

, identified on a radiograph alone]) T-score of –2.5 or less at the femoral neck or spine after appropriate evaluation to exclude secondary causes Low bone mass (T-score between –1.0 and –2.5 at the femoral neck or spine) and a 10-year probability of a hip fracture of 3% or greater or a 10-year probability of a major osteoporosis-related fracture of 20% or greater, based on the US-adapted WHO algorithm for calculating fracture risk ( ) Guidelines from the American Association of Clinical Endocrinologists (...) Women 15.8 52.6 Men 3.9 36 Non-Hispanic black Women 7.7 36.2 Men 1.3 21.3 Hispanic Women 20.4 47.8 Men 5.9 38.3 Source: Wright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res . Nov 2014;29(11):2520-6. . Melton et al reported that the prevalence of hip fractures is higher in white populations, regardless of geographic

2014 eMedicine.com

328. Osteoporosis (Primary) (Diagnosis)

, identified on a radiograph alone]) T-score of –2.5 or less at the femoral neck or spine after appropriate evaluation to exclude secondary causes Low bone mass (T-score between –1.0 and –2.5 at the femoral neck or spine) and a 10-year probability of a hip fracture of 3% or greater or a 10-year probability of a major osteoporosis-related fracture of 20% or greater, based on the US-adapted WHO algorithm for calculating fracture risk ( ) Guidelines from the American Association of Clinical Endocrinologists (...) Women 15.8 52.6 Men 3.9 36 Non-Hispanic black Women 7.7 36.2 Men 1.3 21.3 Hispanic Women 20.4 47.8 Men 5.9 38.3 Source: Wright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res . Nov 2014;29(11):2520-6. . Melton et al reported that the prevalence of hip fractures is higher in white populations, regardless of geographic

2014 eMedicine.com

329. Osteoporosis (Diagnosis)

, identified on a radiograph alone]) T-score of –2.5 or less at the femoral neck or spine after appropriate evaluation to exclude secondary causes Low bone mass (T-score between –1.0 and –2.5 at the femoral neck or spine) and a 10-year probability of a hip fracture of 3% or greater or a 10-year probability of a major osteoporosis-related fracture of 20% or greater, based on the US-adapted WHO algorithm for calculating fracture risk ( ) Guidelines from the American Association of Clinical Endocrinologists (...) Women 15.8 52.6 Men 3.9 36 Non-Hispanic black Women 7.7 36.2 Men 1.3 21.3 Hispanic Women 20.4 47.8 Men 5.9 38.3 Source: Wright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res . Nov 2014;29(11):2520-6. . Melton et al reported that the prevalence of hip fractures is higher in white populations, regardless of geographic

2014 eMedicine.com

330. Neurological History and Physical Examination (Diagnosis)

, if possible.) Radiation (Pay attention to any dermatomal relationship.) Quality (stabbing, stinging, lightninglike, pounding, etc) Severity or quantity (Estimate functional limitation.) Precipitating factors (stress, periods, allergens, sleep deprivation, etc) Relieving factors (sleep, stress management, etc) Diurnal or seasonal variation Important miscellaneous factors of the history include the following: Results of previous attempts to diagnose the condition Any previous therapeutic intervention (...) . Trigeminal: The nerve divides into 3 divisions distal to the Gasserian ganglion. Vagus: The vagabond or wanderer, it travels long distances in the body. Spinal accessory: This nerve is composed of rootlets from the spinal cord in addition to its medullary component. Hypoglossal: Its course is sublingual in the neck. Knowing the names of the CNs makes it easy to remember their function, thereby making their examination self-evident. The following mnemonic is helpful in recalling the names of the CNs: Oh

2014 eMedicine.com

331. Female Athlete Triad (Overview)

counterparts. However, those who have the triad or portions of it are more susceptible to multiple fractures, and they are also more likely to sustain fractures in larger, less commonly affected bones (eg, femoral neck, pelvis, and vertebrae). Other physiologic dysfunction Ongoing research is looking at athletes diagnosed with the female athlete triad and the link to many other psychological and physiological dysfunctions affecting the cardiovascular, renal, hepatic, gastrointestinal, endocrine (...) also occur in the nonathletic population. However, even though this triad was first described at the 1993 meeting of the American College of Sports Medicine (ACSM), [ , ] associations between bone mineral density (BMD), stress fractures, eating disorders, and female athletics had been observed for decades before the syndrome was formally named. The components of the female athlete triad, as put forth by the 1997 ACSM positional stand, consisted of disordered eating, , and . [ ] Not all patients

2014 eMedicine.com

332. Therapeutic Injections for Pain Management (Overview)

can be identified by median branch nerve blocks and then ameliorated with radio-frequency neurotomy or chemical neurolysis. New technologies have evolved, such as the use of spinal cord stimulators and a host of intradiskal procedures, including electrothermal coagulation, percutaneous mechanical disk decompression, laser disc decompression and radiofrequency intradiskal/annular neurolysis. Other new treatment methods include vertebroplasty and kyphoplasty for vertebral fractures. Fluoroscopy (...) and treatment of musculoskeletal disorders. Bursae are fluid-filled sacs that facilitate smooth movement between articulating structures. Subcutaneous bursae, such as the olecranon and prepatellar bursae, form in response to normal external friction. Deep bursae, such as the subacromial bursa, form in response to movement between muscles and bones and may or may not communicate with adjacent joint cavities. "Adventitious" bursae form in response to abnormal shearing stresses (eg, over first metatarsal head

2014 eMedicine.com

333. Temporal/Giant Cell Arteritis (Overview)

may have a role (see ). One school of thought considers GCA and to be different manifestations of the same disease process, while others see them as closely related but different diseases. [ , ] Common signs and symptoms of GCA reflect the involvement of the temporal artery and other medium-sized arteries of the head and the neck and include visual disturbances, headache, jaw claudication, neck pain, and scalp tenderness. Constitutional manifestations, such as fatigue, malaise, and fever, may also (...) infarction (MI) Less often, the descending aorta and mesenteric, renal, iliac, and femoral arteries can be affected, with attendant complications of intestinal infarction, renal infarction, crural infarction, and ischemic mononeuropathies [ , ] Pulmonary arterial involvement has also been described Some veins may be affected occasionally The most common cause of vision loss in GCA is anterior ischemic optic neuropathy (AION). This results from ischemia of the optic nerve head, which is supplied mainly

2014 eMedicine.com

334. Temporal (Giant Cell) Arteritis (Overview)

may have a role (see ). One school of thought considers GCA and to be different manifestations of the same disease process, while others see them as closely related but different diseases. [ , ] Common signs and symptoms of GCA reflect the involvement of the temporal artery and other medium-sized arteries of the head and the neck and include visual disturbances, headache, jaw claudication, neck pain, and scalp tenderness. Constitutional manifestations, such as fatigue, malaise, and fever, may also (...) infarction (MI) Less often, the descending aorta and mesenteric, renal, iliac, and femoral arteries can be affected, with attendant complications of intestinal infarction, renal infarction, crural infarction, and ischemic mononeuropathies [ , ] Pulmonary arterial involvement has also been described Some veins may be affected occasionally The most common cause of vision loss in GCA is anterior ischemic optic neuropathy (AION). This results from ischemia of the optic nerve head, which is supplied mainly

2014 eMedicine.com

335. Sickle Cell Anemia (Overview)

: Young children present with chest pain, fever, cough, tachypnea, leukocytosis, and pulmonary infiltrates in the upper lobes; adults are usually afebrile, dyspneic with severe chest pain, with multilobar/lower lobe disease Pulmonary hypertension: Increasingly recognized as a serious complication of SCD Avascular necrosis of the femoral or humeral head: This is due to vascular occlusion CNS involvement: Most severe manifestation is stroke Ophthalmologic involvement: Ptosis, retinal vascular changes (...) ) CSF examination: Consider LP in febrile children who appear toxic and in those with neurologic findings (eg, neck stiffness, + Brudzinski/Kernig signs, focal deficits); consider CT scanning before performing LP Blood cultures ABGs Secretory phospholipase A2 (sPLA2) In one study of 38 asymptomatic children with SCD, investigators found that hypertension and abnormal blood pressure patterns were prevalent in children with SCD. [ ] They suggested using 24-hour ambulatory BP monitoring (ABPM

2014 eMedicine.com

336. Shock and Pregnancy (Overview)

to gestational age. A blood pressure measurement of 130/80 mm Hg may be normal at term but is abnormal at 28 weeks' gestation, when it should be approximately 110/60 mm Hg. The venous pressure in the legs increases progressively during pregnancy, caused by compression of the pelvic veins and inferior vena cava by the uterus. The elevated femoral venous pressure returns to a normal level following labor. The measurement of brachial artery pressure is not indicative of the uterine arterial blood pressure (...) , multiorgan failure, and death. The clinical signs of cardiogenic shock are distended neck veins, dyspnea, tachypnea, the presence of a third heart sound, systolic or diastolic murmurs, and generalized edema. Peripartum cardiomyopathy is an idiopathic disorder that occurs during the last month of pregnancy and up to 6 months postpartum. The incidence of this disease is 1 case in 1500-4000 deliveries. The risk factors include old age, multiparity, twin gestation, and preeclampsia. Upon presentation

2014 eMedicine.com

337. Cancer and Rehabilitation (Overview)

resources. [ , , ] See the images below. Breast cancer. Transverse rectus abdominis muscle (TRAM) flap. Breast cancer. Transverse rectus abdominis muscle (TRAM) flap. Surgical rehabilitation in head and neck cancer. Preface Physical medicine and rehabilitation (PM&R) is the medical specialty principally concerned with impairments, disabilities, and handicaps that arise after acute or chronic illness. According to the 1980 classification of the World Health Organization (WHO), impairment is physiologic (...) have extensive contact with patients and families, they may be most aware of the family's emotional stress and adjustment issues. Nurses sometimes function as counselors, providing substantial emotional support to patients and their families. In addition to active involvement with representatives of most other disciplines participating in the treatment interventions, nurses are responsible for skin care, bowel and bladder management, and patient and family education. Cancer rehabilitation nurses

2014 eMedicine.com

338. Adult Physiatric History and Examination (Treatment)

of children with acquired brain injuries. Child Care Health Dev . 2009 May 4. . VanWye WR. Patient screening by a physical therapist for nonmusculoskeletal hip pain. Phys Ther . 2009 Mar. 89(3):248-56. . Cooperman TJ, Cuccurullo S, Tanenbaum L, et al. Diagnosis of a C-2 fracture during physiatric consultation: a case report. Am J Phys Med Rehabil . 1998 May-Jun. 77(3):262-6. . Scott MP, Finnoff JT, Davis BA. Femoral neck stress fracture presenting as gluteal pain in a marathon runner: case report. Arch (...) to the emergency department with severe right hip pain that occurred immediately after she fell in her home. Radiographic films confirm a femoral neck fracture, and she undergoes a partial hip replacement (hemiarthroplasty). Because she lives alone, the case manager/social worker for the orthopedics service requests a consultation with physiatrist. Her medical history is significant for rheumatoid arthritis and phlebitis. Review of systems demonstrates a history of falls. She has not had a bowel movement since

2014 eMedicine.com

339. Groin Injury (Treatment)

, in joggers or military recruits), although additional risk factors include relative in young female athletes secondary to or hormonal imbalances, muscle fatigue, changes in foot gear and training, or changes in intensity and/or duration of training. [ ] Stress fractures in the groin or hip can be difficult to diagnose and treat; these injuries most commonly occur at the femoral neck and inferior pubic ramus. Femoral neck stress fractures are especially troublesome because they may lead to AVN (...) of groin injuries. Plain radiographs may show established osteitis pubis, a stress fracture (later stages), osteomyelitis (later stages), a slipped femoral epiphysis (epiphysiolysis), or osteoarthritis. Plain radiographs are useful in demonstrating the presence of hip abnormalities; one study found that 72% of male and 50% of female athletes evaluated with plain radiography demonstrated some evidence of radiographic hip abnormality, such as cam and pincer lesions associated with femoroacetabular

2014 eMedicine.com

340. Giant Cell Arteritis (Treatment)

may have a role (see ). One school of thought considers GCA and to be different manifestations of the same disease process, while others see them as closely related but different diseases. [ , ] Common signs and symptoms of GCA reflect the involvement of the temporal artery and other medium-sized arteries of the head and the neck and include visual disturbances, headache, jaw claudication, neck pain, and scalp tenderness. Constitutional manifestations, such as fatigue, malaise, and fever, may also (...) infarction (MI) Less often, the descending aorta and mesenteric, renal, iliac, and femoral arteries can be affected, with attendant complications of intestinal infarction, renal infarction, crural infarction, and ischemic mononeuropathies [ , ] Pulmonary arterial involvement has also been described Some veins may be affected occasionally The most common cause of vision loss in GCA is anterior ischemic optic neuropathy (AION). This results from ischemia of the optic nerve head, which is supplied mainly

2014 eMedicine.com

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