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Femoral Neck Stress Fracture

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401. Thalassemia (Follow-up)

of healthy controls without osteoporosis and a group of women with postmenopausal osteoporosis (all patients were mostly adults). At baseline, thalassemia patients with osteoporosis had elevated circulating levels of sclerostin compared with healthy controls without osteoporosis and reduced levels of sclerostin compared with postmenopausal women with osteoporosis. Circulating sclerostin levels correlated with bone mineral density in lumbar spine, distal radius, and femoral neck. Zoledronic acid did (...) and treatment. Biomed Res Int . 2015. 2015:813098. . . Musallam KM, Taher AT. Mechanism of renal disease in B-thalassemia. J Am Soc Nephrol . Aug; 2012. 23 (8):1299-302. . Engkakul P, Mahashoklertwattana P, Jaovisidha S, Chuansumrit A, Poomthavorn P, et al. Unrecognized vertebral fractures in adolescents and young adults with thalassemia syndromes. J pediatr Hematol Oncol . Apr; 2013. 35 (3):212-7. . Deborah Chirnomas S, Geukes-Foppen M, Barry K, et al. Practical implications of liver and heart iron load

2014 eMedicine Pediatrics

402. Thoracic Aortic Aneurysm (Treatment)

cerebrospinal drainage, reimplantation of intercostal arteries, evoked potential monitoring, mild hypothermia, and atrial femoral bypass, spinal cord injury still occurs. Endovascular stent grafting has not eliminated spinal cord paraplegia; the incidence varies widely, with an overall incidence of 2.7%. [ , , , ] Complications specific to endovascular stenting include endoleaks, stent fractures, stent graft migration or thrombosis, iliac artery rupture, retrograde dissection, microembolization (...) artery. Distally, a sufficient landing zone of 2 cm prior to the celiac artery is required. The aortic inner neck diameters in the proximal and distal landing zones must fall within 23-37 mm. In addition, appropriately sized femoral and iliac arteries (typically >8 mm in diameter) that lack tortuosity and calcium are required for implantation. TAAAs, accounting for approximately 10% of thoracic aneurysms, may be repaired with the use of a partial bypass of the left atrium to the femoral artery

2014 eMedicine Surgery

403. Osteoporosis (Diagnosis)

) is the preferred method for assessing BMC and areal BMD (aBMD) in children and adolescents. 4 Although population-based data on the relationship between BMD and fracture are still limited, population-based reference curves for DXA assessments of BMC and aBMD for total body less head (TBLH), lumbar spine, hip, femoral neck and distal one-third radius for black and nonblack children in the United States are now available from the Bone Mineral Density in Childhood Study (BMDCS). [ ] Unlike in adults, where (...) outcome study in 144 young adults who were born with very low birth weight and were studied around the time of peak bone mass have significantly lower BMD at the lumbar spine and femoral neck compared to term-born peers. [ ] Some studies have evaluated the impact of bone-involving diseases during childhood (anorexia nervosa, malignancy, and juvenile rheumatoid arthritis) on BMD and fracture risk in adult age. [ , , ] These have demonstrated that even after resolution of some childhood diseases

2014 eMedicine Pediatrics

404. Pediatrics, Sickle Cell Disease (Diagnosis)

chest syndrome: 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 (...) , fractionated bilirubin) 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

2014 eMedicine Emergency Medicine

405. Pediatrics, Child Abuse (Diagnosis)

Jr, Wells L. Complete distal femoral metaphyseal fractures: a harbinger of child abuse before walking age. J Pediatr Orthop . 2007 Oct-Nov. 27(7):751-3. . Kleinman PK, Perez-Rossello JM, Newton AW, Feldman HA, Kleinman PL. Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. AJR Am J Roentgenol . 2011 Oct. 197(4):1005-8. . Helfer RE, Slovis TL, Black M. Injuries resulting when small children fall out of bed. Pediatrics . 1977 Oct. 60(4):533-5. . Lyons TJ (...) for meningitis can save a child’s life. In addition, toxic stress in childhood can affect the victim's long term physical and mental health. In the United States, medical providers are mandated reporters of child abuse. [ ] The EM provider is obligated to report when there is a reasonable suspicion of child abuse. The provider is not legally responsible for reporting in good faith if the suspicion cannot be proven, but the provider can be held legally responsible for not reporting a reasonable suspicion

2014 eMedicine Emergency Medicine

406. Anemia, Sickle Cell (Diagnosis)

: 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 Emergency Medicine

407. 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

408. 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

409. 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

410. 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

411. 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

412. 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

413. 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

414. 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

415. 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

416. 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

417. 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

418. 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

419. 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

420. 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

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