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Femoral Neck Stress Fracture

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341. Geriatric Rehabilitation (Treatment)

and mobility, and a lack of participation in activities. Vision, proprioception, and vestibular function are the 3 main components of sensory feedback to maintain normal upright stance. Therefore, a loss of vision is associated with an increased risk of falling with a consequent increased risk of hip fractures. The patient's mental health can also deteriorate with vision loss, and the effects can include depressive episodes. Social isolation, in which the person feels left out and lonely, can lead (...) with ambulation, transferring, meal preparation, and managing their medication regimen. According to the 1999 Surveillance for the Sensory Impaired study, older adults who reported vision and hearing loss were more likely than those without sensory impairment to have had the following: (1) a fall during the preceding year (37.4% vs 19.8%), (2) a hip fracture (7.6% vs 4.5%), (3) a higher reported prevalence of hypertension (53.4% vs 44.3%), and (4) a higher rate of heart disease (32.2% vs 20.6%). In addition

2014 eMedicine.com

342. Female Athlete Triad (Treatment)

at the earliest sign of a cardiac abnormality. Few patients with anorexia complain of the classic chest pain or shortness of breath until late in the course of the disease. If the athlete develops a fracture or stress fracture that requires surgical intervention, referral to an orthopedist is needed. Many such injuries can be managed nonoperatively; however, femoral neck stress fractures or compression vertebral fractures may require consultation with a specialist. If casts or braces are needed, they may have (...) supplementation should be between 1300 and 1500 mg/day and Vitamin D between 1500 and 2000 mg/day with a goal of a Vitamin D level of 32-50 ng/ml. [ , ] Other treatments can be directed at secondary musculoskeletal problems that may arise, but the focus should remain on the underlying problem of the triad. Initial treatment may involve immobilizing any stress fractures or prescribing a period of rest from athletic activities to allow the body to heal as much as possible. Physical therapy may be appropriate

2014 eMedicine.com

343. Assistive Devices to Improve Independence (Treatment)

decreased physical endurance and mobility, and a lack of participation in activities. Vision, proprioception, and vestibular function are the 3 main components of sensory feedback to maintain normal upright stance. Therefore, a loss of vision is associated with an increased risk of falling with a consequent increased risk of hip fractures. The patient's mental health can also deteriorate with vision loss, and the effects can include depressive episodes. Social isolation, in which the person feels left (...) without such impairments to have difficulty with ambulation, transferring, meal preparation, and managing their medication regimen. According to the 1999 Surveillance for the Sensory Impaired study, older adults who reported vision and hearing loss were more likely than those without sensory impairment to have had the following: (1) a fall during the preceding year (37.4% vs 19.8%), (2) a hip fracture (7.6% vs 4.5%), (3) a higher reported prevalence of hypertension (53.4% vs 44.3%), and (4) a higher

2014 eMedicine.com

344. Cancer and Rehabilitation (Treatment)

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

345. Osteoporosis (Primary) (Treatment)

antibody that binds with and inhibits sclerosin, and thus both increases bone formation and decreases bone resorption. It has been shown to reduce vertebral fracture rates in postmenopausal women with osteoporosis. [ ] In the Fracture Study in Postmenopausal Women With Osteoporosis (FRAME), a phase 3 randomized trial, 7180 postmenopausal women who had a T score of -2.5 to -3.5 at the total hip or femoral neck, 1 year of treatment with romosozumab reduced vertebral fracture rates by 73% compared (...) ) to warn against atypical subtrochanteric and diaphyseal femoral fractures in patients who have received bisphosphonate therapy including zoledronic acid. Fractures occur with minimal or no trauma and may present as groin pain weeks to months after fracture [ ] In November 2012, the FDA made safety labeling changes for zoledronic acid to warn against the following adverse reactions [ ] : Acute phase reaction within 3 days of zoledronic acid administration: symptoms include pyrexia, fatigue, bone pain

2014 eMedicine.com

346. Osteoporosis (Treatment)

antibody that binds with and inhibits sclerosin, and thus both increases bone formation and decreases bone resorption. It has been shown to reduce vertebral fracture rates in postmenopausal women with osteoporosis. [ ] In the Fracture Study in Postmenopausal Women With Osteoporosis (FRAME), a phase 3 randomized trial, 7180 postmenopausal women who had a T score of -2.5 to -3.5 at the total hip or femoral neck, 1 year of treatment with romosozumab reduced vertebral fracture rates by 73% compared (...) ) to warn against atypical subtrochanteric and diaphyseal femoral fractures in patients who have received bisphosphonate therapy including zoledronic acid. Fractures occur with minimal or no trauma and may present as groin pain weeks to months after fracture [ ] In November 2012, the FDA made safety labeling changes for zoledronic acid to warn against the following adverse reactions [ ] : Acute phase reaction within 3 days of zoledronic acid administration: symptoms include pyrexia, fatigue, bone pain

2014 eMedicine.com

347. Osteoporosis (Secondary) (Treatment)

antibody that binds with and inhibits sclerosin, and thus both increases bone formation and decreases bone resorption. It has been shown to reduce vertebral fracture rates in postmenopausal women with osteoporosis. [ ] In the Fracture Study in Postmenopausal Women With Osteoporosis (FRAME), a phase 3 randomized trial, 7180 postmenopausal women who had a T score of -2.5 to -3.5 at the total hip or femoral neck, 1 year of treatment with romosozumab reduced vertebral fracture rates by 73% compared (...) ) to warn against atypical subtrochanteric and diaphyseal femoral fractures in patients who have received bisphosphonate therapy including zoledronic acid. Fractures occur with minimal or no trauma and may present as groin pain weeks to months after fracture [ ] In November 2012, the FDA made safety labeling changes for zoledronic acid to warn against the following adverse reactions [ ] : Acute phase reaction within 3 days of zoledronic acid administration: symptoms include pyrexia, fatigue, bone pain

2014 eMedicine.com

348. Urological Management in Neurological Disease (Treatment)

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

349. Low Energy Availability in the Female Athlete (Treatment)

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

350. Neurological History and Physical Examination (Treatment)

, 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

351. Shock and Pregnancy (Treatment)

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

352. Therapeutic Injections for Pain Management (Treatment)

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

353. Neurological History and Physical Examination (Overview)

, 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

354. The Approach to the Painful Joint (Treatment)

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

355. Temporal (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

356. Temporal/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

357. Overuse Injury (Overview)

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

358. Osteoporosis (Secondary) (Overview)

, 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

359. Osteoporosis (Overview)

, 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

360. Osteoporosis (Primary) (Overview)

, 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

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