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Femoral Neck Stress Fracture

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441. 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

442. 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

443. 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

444. Assistive Devices to Improve Independence (Diagnosis)

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

445. Avascular Necrosis (Diagnosis)

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

446. Cancer and Rehabilitation (Diagnosis)

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

447. Child Abuse and Neglect: Physical Abuse (Overview)

are strong and relatively more resistant to stress than the bone and cartilage, which accounts for less joint dislocations and ligamentous tears in childhood. Finally, bone healing is more rapid in children than in adults, which makes dating of childhood fractures more complicated. Types of fractures While certain types of fractures (eg posterior rib, scapular, classic metaphyseal lesions) are more common in physical abuse than accidental injury, there is no fracture that is pathognomonic for child (...) follow-up film with sclerotic fracture line and periosteal new bone healing. Metaphyseal fractures (also called corner fractures or bucket handle fractures) are microfractures through the immature part of the bone edge and often appear like chips or corner fractures on radiographs. The metaphysis is an area of rapid bone turnover in the growing infant and toddler. Metaphyseal fractures are specific to infants as they involve the immature physis; they are caused by shearing and tensile stress seen

2014 eMedicine Pediatrics

448. Bone Marrow Transplantation, Long-Term Effects (Overview)

conditioned with and cyclophosphamide without TBI experienced severe ovarian failure that required estrogen replacement. [ ] This stresses the importance of both TBI and alkylating agents in the etiology of ovarian failure in females undergoing HSCT. Ovarian failure or premature menopause often manifests with high levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) with or without decreased estrogen levels, although all eventually progress to a low-estrogen state. Measurements (...) of antimullerian hormone (AMH) may be useful in assessing ovarian reserve. [ ] Similar to postmenopausal women with low estrogen levels, females who experience acute ovarian failure or premature menopause following HSCT seem to be at risk for early reduced bone mineral density, [ ] bone fractures, [ ] lipid disorders, and ischemic heart disease. [ , , ] Use of steroids and radiotherapy can potentiate the risk of reduced bone mineral density. Ovarian failure after HSCT responds well to estrogen replacement

2014 eMedicine Pediatrics

449. Marfan Syndrome (Treatment)

stretching (stress fractures of the femoral neck due to stretching can occur), [ ] weight extension on an abduction frame, local heating, and reeducation concerning daily activities. [ ] Myopia is treatable with refraction correction. Patients with flat feet may wear shoes with adequate arch support, although custom orthotics may be required. have been established. [ ] Psychological counseling is helpful for families coping with feelings of denial, anger, blame, depression, or guilt. Future therapeutic (...) basicervical femoral neck fractures in a patient with Marfan syndrome. Am J Orthop . 1997 Oct. 26(10):689-91. . [Guideline] Harris EJ, Vanore JV, Thomas JL, et al. Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg . 2004 Nov-Dec. 43(6):341-73. . Habashi JP, Judge DP, Holm TM, et al. Losartan, an AT1 antagonist, prevents aortic aneurysm in a mouse model of Marfan syndrome. Science . 2006 Apr 7. 312(5770):117-21. . . Brooke BS, Habashi JP, Judge DP, Patel N, Loeys B, Dietz HC 3rd. Angiotensin

2014 eMedicine Pediatrics

450. Osteoporosis (Overview)

) 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

451. 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

452. 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

453. 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

454. 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

455. 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

456. 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

457. Adult Physiatric History and Examination (Follow-up)

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

458. 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

459. 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

460. Sickle Cell Anemia (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.com

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