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Femoral Neck Stress Fracture

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361. Low Energy Availability in the Female Athlete (Overview)

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

362. Groin Injury (Overview)

, 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

363. Geriatric Rehabilitation (Overview)

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

364. Giant Cell Arteritis (Overview)

). 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 be present. (See .) GCA (...) 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

365. Giant Cell Arteritis (Overview)

). 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 be present. (See .) GCA (...) 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

366. Urological Management in Neurological Disease (Overview)

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

367. The Approach to the Painful Joint (Overview)

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

368. Osteoporosis (Primary) (Follow-up)

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

369. Osteoporosis (Secondary) (Follow-up)

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

370. Osteoporosis (Follow-up)

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

371. Hip Dislocation (Follow-up)

indentation fracture of the femoral neck: a case report. J Trauma . 2007 Jun. 62(6):E4-6. . Cooper DE, Warren RF, Barnes R. Traumatic subluxation of the hip resulting in aseptic necrosis and chondrolysis in a professional football player. Am J Sports Med . 1991 May-Jun. 19(3):322-4. . Thanacharoenpanich S, Bixby S, Breen MA, Kim YJ. MRI is Better Than CT Scan for Detection of Structural Pathologies After Traumatic Posterior Hip Dislocations in Children and Adolescents. J Pediatr Orthop . 2018 Jan 19 (...) with traumatic posterior hip dislocations. Am J Emerg Med . 2003 Nov. 21(7):545-8. . Seltzer SE, Weissman BN, Braunstein EM, et al. Indications for CT scanning in orthopedic disorders of hip. Orthop Rev . 1983. 12:29-40. Epstein HC. Posterior fracture-dislocations of the hip: comparison of open and closed methods of treatment in certain types. J Bone Joint Surg Am . Dec 1961. 43A:1079-98. . Cash DJ, Nolan JF. Avascular necrosis of the femoral head 8 years after posterior hip dislocation. Injury . 2007 Jul

2014 eMedicine.com

372. Assistive Devices to Improve Independence (Overview)

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

373. Adult Physiatric History and Examination (Overview)

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

374. Avascular Necrosis (Overview)

factors such as direct (eg, , dislocation), nontraumatic stress, and stress fracture. Altered lipid metabolism: Animal studies have led to the hypothesis that increased levels of serum lipids leads to lipid deposition in the femoral head, causing femoral hypertension and ischemia. [ ] Lipid-level–lowering drugs in animals reverse this process. Corticosteroid administration was associated with fat emboli in the femoral heads of rabbits. [ ] : Disorders of the coagulation system have been implicated (...) or fifth decade of life and is bilateral in more than half of cases. Previous References Bose VC, Baruah BD. Resurfacing arthroplasty of the hip for avascular necrosis of the femoral head: a minimum follow-up of four years. J Bone Joint Surg Br . 2010 Jul. 92(7):922-8. . Steffen RT, Athanasou NA, Gill HS, Murray DW. Avascular necrosis associated with fracture of the femoral neck after hip resurfacing: histological assessment of femoral bone from retrieval specimens. J Bone Joint Surg Br . 2010 Jun. 92

2014 eMedicine.com

375. Low Energy Availability in the Female Athlete (Follow-up)

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

376. Mechanical Low Back Pain (Follow-up)

-threatening cause for the mechanical LBP (eg, tumor on the spine, fracture of the axial spine), consideration should be given to transferring the patient to an appropriate outpatient care facility or to an inpatient rehabilitation unit for pain management, reconditioning of muscles, and preventive treatment. Previous Next: Deterrence See the list below: Prevention of most cases of mechanical low back pain (LBP) can be achieved using good biomechanical principles when performing heavy manual labor (...) of the expectations of key players (eg, family, physician, employer) compared with his or her own goals. Posture, reconditioning, proper nutrition, and stress management also should be addressed. For patient education resources, see the patient education articles , , and . Previous References Institute for Clinical Systems Improvement. Adult low back pain. Bloomington, Minn: Institute for Clinical Systems Improvement; . Sept 2005. National Guideline Clearinghouse. Listing of Guidelines for Low Back Pain. Accessed

2014 eMedicine.com

377. Neurological History and Physical Examination (Follow-up)

, 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

378. Embolization, Vascular Lesions

to an arteriovenous malformation." [ ] Venous malformations are the most common vascular malformation and are generally found in the head and neck area or in the extremities. Accurate diagnosis is necessary to establish cause and determine treatment. The International Society for the Study of Vascular Anomalies has divided vascular malformations into simple and combined types. The simple types include capillary, venous, and lymphatic malformations. Combined types include arteriovenous malformation (...) to be displaced by the vascular malformation. Axial CT image through the upper part of the neck after percutaneous cyanoacrylate embolization. The patient was a young girl with an extensive head and neck venous malformation resulting in significant airway obstruction, which required a tracheostomy. Embolization may have 3 therapeutic goals: An adjunctive goal (eg, preoperative, adjunct to chemotherapy or radiation therapy) A curative goal (eg, definitive treatment such as that performed in cases of aneurysms

2014 eMedicine Radiology

379. Fibrous Dysplasia

. [ , , ] Next: Radiography Common locations for lesions are the ribs, craniofacial bones, femoral neck, tibia, and pelvis. Radiographic findings in these and other structures are discussed below. [ ] Long and short tubular bones The usual appearance of fibrous dysplasia includes a lucent lesion in the diaphysis or metaphysis, with endosteal scalloping and with or without bone expansion and the absence of periosteal reaction. Usually, the matrix of the lucency is smooth and relatively homogeneous (...) of the radioisotope tracer technetium-99m methylene diphosphonate ( 99m Tc MDP) occurs in the spine, pelvis, ribs, and appendicular skeleton. Pathologic or stress fractures also can increase isotopic activity in the lesions. The features on the bone scan are nonspecific for a conclusive diagnosis based solely on the distribution of the isotope. [ , ] Degree of confidence The technique is not specific for a firm diagnosis based on the imaging characteristics. The specificity is relatively poor. Previous References

2014 eMedicine Radiology

380. Hip Replacement

fractures may involve the greater trochanter, femoral neck, acetabulum, and femoral diaphysis; these fractures may be related to trauma, stress shielding, or component loosening. [ ] (For depictions of these types of hardware failure, see the images below.) Image from a patient who had a prosthesis failure from a cemented unipolar hemiarthroplasty. This anteroposterior radiograph shows a femoral stem fracture (arrow). Image from a patient who had a prosthesis failure from a total hip arthroplasty (...) from a patient who had a resurfacing hemiarthroplasty. This frog-leg radiograph shows a displaced osseous femoral neck fracture (arrows) adjacent to the hip arthroplasty. The hip joint may be replaced with a variety of materials, including metal, polyethylene, and ceramic. The acetabular component may be built of a single piece of polyethylene, metal, or ceramic or may be modular and composed of a metal backing and a liner made of polyethylene, ceramic, or metal. [ ] The femoral component may

2014 eMedicine Radiology

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