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Posterior Night Splint

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81. The Approach to the Painful Joint (Overview)

of the provocative occupational or athletic activity, shoe modification, a heel lift to reduce tendon stretching during walking, and NSAID therapy. Physical therapy includes local heat application, gentle stretching exercises, and a temporary splint with slight plantar flexion. Retrocalcaneal bursitis (see ) is inflammation of the retrocalcaneal bursa, resulting in pain and tenderness at the back of the heel. The area anterior to the Achilles tendon and posterior to the calcaneus is tender; passive dorsiflexion (...) , spine, or knees may also have pain at rest and at night. Pain that arises from small peripheral joints tends to be more accurately localized than pain arising from larger proximal joints. For example, pain arising from the hip joint may be felt in the groin or buttocks, in the anterior portion of the thigh, or in the knee. Stiffness is a perceived sensation of tightness when attempts are made to move joints after a period of inactivity. It typically subsides over time. Its duration may serve

2014 eMedicine.com

82. Leprosy (Follow-up)

of the fibula Superficial peroneal nerves in front of the ankles Posterior tibial nerves immediately below the internal malleoli Sural nerves In TT disease, thickening is usually confined to 1 nerve. In lepromatous (LL) disease, the increase in nerve size is symmetrical; however, the degree of nerve thickening may differ between the 2 sides. The enlargement often may be segmental rather than diffuse and uniform. Disparity may be noted between specific areas of thickened nerves and distribution of sensory (...) after clinical cure and release from treatment. Local treatment measures include the following: Appropriate splints (eg, for wrist drop or foot drop) Exercises Prevention of corneal exposure when the facial nerve is involved Prevention of injuries to anesthetic areas Prevention and protection of plantar ulcers through the wearing of special controlled-rigidity footwear for redistributing pressure Rest, splints, and physiotherapeutic measures may be appropriate. Thalidomide is not useful for reversal

2014 eMedicine.com

83. Assistive Devices to Improve Independence (Overview)

; and diabetic retinopathy (eg, microaneurysms, dot hemorrhages), which can be managed with glycemic control or laser surgery. The result of these various changes is a loss of visual acuity, decrease in peripheral vision, and a decline in dark adaptation ability. These visual impairments are related to a higher incidence of falls in the geriatric population, especially at night. Correction and management of visual impairment In the majority of the geriatric population, eyeglasses are sufficient to correct (...) thick carpet, repairing unstable furniture, and installing good lighting. A well-lit pathway to the bathroom that is clear of clutter must be emphasized. Large touch-lights or automatic sensory lights, which do not require dexterity, can be placed at the patient's bedside or in other areas to help decrease the risk of falls, especially at night. Motion-detector lights are helpful in providing illumination (eg, to the bathroom) at night. Falls in the shower and bathtub are the third leading cause

2014 eMedicine.com

84. Rehabilitation Management of Neuromuscular Disease (Follow-up)

is hypoventilation, which leads to hypercapnia (elevated carbon dioxide levels in the blood). End-tidal carbon dioxide levels or arterial blood gases should be periodically measured, depending on the clinical circumstances. Pulse oximetry, which measures only oxygen saturation levels, may be inadequate. Performing a thorough review of systems is important. Patients who are hypoventilating become hypercapnic at night and experience a morning headache as a result. They may also have nocturnal restlessness (...) , mainly at night, may initially avoid the need for tracheostomy and maintain a reasonable quality of life (QOL). However, bulbar palsy may occur in ALS and in some rare forms of SMA. In such cases, if better airway access becomes necessary and an informed patient wishes more aggressive care, a tracheostomy may be performed. However, an alternative procedure, laryngeal diversion (or laryngotracheal separation), has several distinct advantages over tracheostomy. In laryngeal diversion, the trachea

2014 eMedicine.com

85. Plantar Fasciitis (Follow-up)

, NSAID therapy, strapping and taping, and over-the-counter (OTC) orthoses. Counseling as to activity modification, as well as choice of shoe gear, is important. After 6 weeks, recalcitrant cases should be treated additionally with a night splint and, possibly, an injection, along with the initial regimen for another 6 weeks. If pain persists, referral to a foot and ankle specialist should be considered. Injection therapy, immobilization in a cast or walker boot, physical therapy, and custom orthotics (...) in patients with chronic plantar fasciitis that does not respond to conservative management. IPST may be considered before surgery when ESWT devices are not available. A randomized, double-blind, prospective clinical pilot study showed that IPST is safe and effective; however, the exact mechanism is unknown and thus warrants further research. [ ] Previous Next: Splints and Orthoses Night splints Most people naturally sleep with their feet in a plantar-flexed position, which causes the plantar fascia

2014 eMedicine.com

86. Plantar Fasciitis (Follow-up)

. [ ] Commonly prescribed silicone inserts are effective in reducing pain and increasing functions in the short term. Both affordable and readily available, popular recommendation includes first-line treatment with silicone orthotics for patients with plantar fasciitis. [ ] Combined use of foot orthoses and night splits may provide better outcomes than either modality alone. [ ] Dorsiflexing both the ankle and metatarsophalangeal joints can reduce the tension of the posterior calf along with the plantar (...) fascia, thereby reducing pain. These modalities can be applied both during the day, while being active, and at night, increasing the chance of pain reduction. [ ] While evidence has been somewhat inconsistent regarding the effectiveness of night splints and orthoses used separately for reducing pain caused by plantar fasciitis, recent studies suggest that the treatment protocol combining the 2 modalities is more effective than orthotics alone in relieving foot pain in patients with plantar fasciitis

2014 eMedicine.com

87. Obstructive Sleep Apnea-Hypopnea Syndrome (Follow-up)

. The first image in each series depicts the baseline upper airway narrowing present in this patient. Effectively, CPAP acts as a pneumatic splint to maintain UA patency during sleep, preventing the soft tissues from collapsing. By this mechanism, it effectively eliminates the apneas and/or hypopneas, decreases the arousals, and normalizes the oxygen saturation (see the image below). Effect of nasal continuous positive airway pressure (CPAP) on oxygen saturation in sleep apnea. The upper portion (...) of this figure shows the raw oxygen saturation trace from 1 night of a sleep study. Below the raw trace are vertical lines that indicate the presence of either an apnea or hypopnea. Before CPAP, frequent respiratory events with significant desaturations occurred. During the night, CPAP was applied, resulting in the elimination of the apnea and hypopneas and normalization of the oxygen trace. Guidelines for use Patients with severe SDB (respiratory disturbance index [RDI] >20-30) should be treated

2014 eMedicine.com

88. Obstructive Sleep Apnea (Follow-up)

. The first image in each series depicts the baseline upper airway narrowing present in this patient. Effectively, CPAP acts as a pneumatic splint to maintain UA patency during sleep, preventing the soft tissues from collapsing. By this mechanism, it effectively eliminates the apneas and/or hypopneas, decreases the arousals, and normalizes the oxygen saturation (see the image below). Effect of nasal continuous positive airway pressure (CPAP) on oxygen saturation in sleep apnea. The upper portion (...) of this figure shows the raw oxygen saturation trace from 1 night of a sleep study. Below the raw trace are vertical lines that indicate the presence of either an apnea or hypopnea. Before CPAP, frequent respiratory events with significant desaturations occurred. During the night, CPAP was applied, resulting in the elimination of the apnea and hypopneas and normalization of the oxygen trace. Guidelines for use Patients with severe SDB (respiratory disturbance index [RDI] >20-30) should be treated

2014 eMedicine.com

89. Neuropathy of Leprosy (Follow-up)

around the neck of the fibula Superficial peroneal nerves in front of the ankles Posterior tibial nerves immediately below the internal malleoli Sural nerves In TT disease, thickening is usually confined to 1 nerve. In lepromatous (LL) disease, the increase in nerve size is symmetrical; however, the degree of nerve thickening may differ between the 2 sides. The enlargement often may be segmental rather than diffuse and uniform. Disparity may be noted between specific areas of thickened nerves (...) after clinical cure and release from treatment. Local treatment measures include the following: Appropriate splints (eg, for wrist drop or foot drop) Exercises Prevention of corneal exposure when the facial nerve is involved Prevention of injuries to anesthetic areas Prevention and protection of plantar ulcers through the wearing of special controlled-rigidity footwear for redistributing pressure Rest, splints, and physiotherapeutic measures may be appropriate. Thalidomide is not useful for reversal

2014 eMedicine.com

90. Middle Cerebral Artery Stroke (Follow-up)

by cerebrovascular accident. The MCA supplies most of the outer convex brain surface, nearly all the basal ganglia, and the posterior and anterior internal capsules. Infarcts that occur within the vast distribution of this vessel lead to diverse neurologic sequelae. Understanding these neurologic deficits and their correlation to specific MCA territories has long been researched. Research has also focused on the correlation between specific neurologic deficits after and differing outcomes and prognoses (...) spasticity. Bracing, especially at night, allows continuous passive range to tight, spastic muscle. This includes serial casting, which allows gradual increase in range over weeks. [ ] Oral medications also are often used for spasticity management, including tizanidine, baclofen, dantrolene, and benzodiazepines. . The functional benefit of these drugs is not well demonstrated despite their common use. These medications often have at least some sedating effect on patients, which should be weighed

2014 eMedicine.com

91. Hand, Nerve Compression Syndromes: Upper Extremity

with advanced cases. Studies EMG or a nerve conduction velocity study can be used in difficult cases or with polyneuropathy. [ ] Occasionally, radiographs help rule out occult fractures, a foreign body, or tumors. Laboratory studies may include an erythrocyte sedimentation rate, blood glucose value, thyroid evaluation, and rheumatoid factor. Treatment Nonsurgical measures include wrist splinting in a neutral position to minimize intratunnel pressures at night due to posture; anti-inflammatory medications (...) The ulnar nerve arises from the medial cord of the brachial plexus. The ulnar nerve travels posterior to the brachial artery and remains within the flexor compartment of the upper extremity until it reaches the medial epicondyle. The nerve travels behind the medial epicondyle back into the flexor compartment underneath the flexor musculature. Above the elbow, the ulnar nerve lies on the long head and then the medial head of the triceps muscle, directly posterior to the medial intermuscular septum

2014 eMedicine Surgery

92. Hand, Fracture and Dislocations: Thumb

nonoperative. Continuous undisturbed splinting in extension for 6 weeks should be followed by night splinting in extension for an additional 6-8 weeks. Operative indications include open injury, failed closed treatment, chronic injury and/or mal-union, or a mallet thumb with bony avulsion. Thumb IP Dislocations Thumb IP dislocations generally are easily reduced in a closed manner. Operative indications include an irreducible dislocation or unstable IP joint after relocation, open injury, and chronic (...) by the anterior (volar) and posterior oblique ligaments, anterior and posterior intermetacarpal ligaments, and the dorsal radial ligament. Thumb metacarpal base fractures are classified into extra-articular and intra-articular. Intra-articular fractures are more common and are subdivided into Bennett fractures, Rolando fractures, and comminuted fractures. Extra-articular fractures at the base of the thumb metacarpal are common, are usually transverse or oblique, and occur at the proximal metaphyseal

2014 eMedicine Surgery

93. Hand, Rheumatoid Hand

after the procedure, the patient is fitted for a dynamic outrigger splint that maintains extension in an appropriate anatomic position of the fingers while the patient undergoes active flexion exercises. Night splints are manufactured to maintain the fingers in extension. Splinting is required for the next 4-8 weeks. Follow-up radiographs are obtained to confirm the appropriate positioning of the implants. Crossed intrinsic transfer of the extensor tendons from the ulnar side to the radial side (...) this problem should be considered. First, MP joint dislocation produces a fixed deformity with a flexed and ulnarly deviated finger. Second, volar and ulnar subluxation of the extensor tendons into the gutters between the phalanges limits extensor function as the extensors essentially become flexors in this position. In this condition, the patient can sometimes maintain MP extension actively after the finger is passively extended. Finally, paralysis due to posterior interosseous nerve compression can also

2014 eMedicine Surgery

94. Hand, Nerve Injury Repair

and regained at different times. Motor fibers are the first lost and the last regained, while pain and sympathetic fibers are the opposite. [ ] Common examples of this kind of injury include pressure palsies such as those that result from a tourniquet or from sleeping with pressure on a nerve, eg, Saturday night palsy. [ ] Axonotmesis (axon cutting), which occasionally is grouped with neurapraxia, describes the situation when axons, myelin, and associated internal nerve structures are disrupted (...) distribution as on the volar surface. [ , ] Motor targets of the ulnar nerve are as follows: Flexor carpi ulnaris Flexor digitorum profundus Hypothenar muscles All interossei Third and fourth lumbricals Adductor pollicis Flexor pollicis brevis - Deep head Radial nerve The radial nerve is a branch off the posterior cord and contains fibers from roots C7-T1. [ ] This nerve wraps around the humerus in the spiral groove as it passes through the upper arm, supplying motor innervation to all 3 heads

2014 eMedicine Surgery

95. Plantar Fasciitis (Diagnosis)

effort to maintain a heel-cord stretching program or to wear a night splint. They should also be taught proper performance of a home exercise program involving stretching the plantar fascia. The following recommendations are appropriate: Wear shoes with adequate arch support and cushioned heels; discard old running shoes and wear new ones; rotate work shoes daily Avoid long periods of standing Lose weight Stretch the plantar fascia and warm up the lower extremity before participating in exercise (...) Podiatr Med Assoc . 2001 Feb. 91(2):55-62. . Batt ME, Tanji JL, Skattum N. Plantar fasciitis: a prospective randomized clinical trial of the tension night splint. Clin J Sport Med . 1996 Jul. 6(3):158-62. . Wapner KL, Sharkey PF. The use of night splints for treatment of recalcitrant plantar fasciitis. Foot Ankle . 1991 Dec. 12(3):135-7. . Powell M, Post WR, Keener J, Wearden S. Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome

2014 eMedicine Surgery

96. Plantar Heel Pain (Diagnosis)

. J Bone Joint Surg Am . 2010 Nov 3. 92 (15):2514-22. . Berlet GC, Anderson RB, Davis H, Kiebzak GM. A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the Ankle Dorsiflexion Dynasplint. Orthopedics . 2002 Nov. 25 (11):1273-5. . Attard J, Singh D. A comparison of two night ankle-foot orthoses used in the treatment of inferior heel pain: a preliminary investigation. Foot Ankle Surg . 2012 Jun. 18 (2):108-10. . Tisdel CL, Harper MC. Chronic plantar heel pain (...) Soft heel cushion to absorb shock. Soft heel cushion and a cup. Custom-molded orthotic. Stretching exercise. Lean against the wall with the knee kept straight and the heel touching the floor. Stretching the back of the leg at the edge of a stair. Massaging and stretching the plantar fascia using a can. A night splint applied on back of the leg and foot. A night splint applied on the front of the leg. Lateral radiograph of the hindfoot showing a cyst in the anterior aspect of the calcaneus in a 19

2014 eMedicine Surgery

97. Cubital Tunnel Syndrome (Diagnosis)

, 2018 Author: Charles F Guardia, III, MD; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE Share Email Print Feedback Close Sections Sections Ulnar Neuropathy Overview Background The ulnar nerve is an extension of the medial cord of the brachial plexus. It is a mixed nerve that supplies innervation to muscles in the forearm and hand and provides sensation over the medial half of the fourth digit and the entire fifth digit (the ulnar aspect of the palm) and the ulnar portion of the posterior aspect (...) appear to be satisfactory. Next: Anatomy Course of ulnar nerve The ulnar nerve is the terminal branch of the medial cord of the brachial plexus and contains fibers from C8, T1, and, occasionally, C7. [ , ] It enters the arm with the axillary artery and passes posterior and medial to the brachial artery, traveling between the brachial artery and the brachial vein. At the level of the insertion of the coracobrachialis in the middle third of the arm, the ulnar nerve pierces the medial intermuscular

2014 eMedicine Surgery

98. Cubital Tunnel Syndrome (Overview)

Author: Charles F Guardia, III, MD; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE Share Email Print Feedback Close Sections Sections Ulnar Neuropathy Overview Background The ulnar nerve is an extension of the medial cord of the brachial plexus. It is a mixed nerve that supplies innervation to muscles in the forearm and hand and provides sensation over the medial half of the fourth digit and the entire fifth digit (the ulnar aspect of the palm) and the ulnar portion of the posterior aspect of the hand (...) to be satisfactory. Next: Anatomy Course of ulnar nerve The ulnar nerve is the terminal branch of the medial cord of the brachial plexus and contains fibers from C8, T1, and, occasionally, C7. [ , ] It enters the arm with the axillary artery and passes posterior and medial to the brachial artery, traveling between the brachial artery and the brachial vein. At the level of the insertion of the coracobrachialis in the middle third of the arm, the ulnar nerve pierces the medial intermuscular septum to enter

2014 eMedicine Surgery

99. Snoring and Obstructive Sleep Apnea, Physiologic Approach

effort could stimulate arousal. The clinical relevance of RERA is not as well documented as the apnea-hypopnea index (AHI), but RERA is assumed to impact daytime somnolence. When patients are noted to have several RERAs but have a clinically insignificant AHI, they are often thought to have UARS. Patients with UARS often present with daytime somnolence and snoring. These patients may display anthropomorphic abnormalities and decreased posterior airspace with retrodisplacement of the tongue. Airflow (...) desaturation or the number of arousals throughout the night. Both of these could be indices for daytime symptoms and pathogenic sequelae of the disorder. Obstructive sleep apnea syndrome Obstructive sleep apnea syndrome (OSAS) is defined as a chronic respiratory sleep disorder typified by recurrent episodes of partial or complete upper airway obstruction during sleep that cause cessation of airflow in the presence of respiratory effort. These episodes cause repeated arousals and fragmented sleep

2014 eMedicine Surgery

100. Tendon Transfers (Diagnosis)

is performed in an end-to-side manner so that if reinnervation occurs, the continuity of the reinnervated ECRB is not lost. Low-profile dynamic splints can be worn during the day, with night splints maintaining the digits and wrist in extension. [ ] All joints must maintain full passive range of motion, including the first web space. During World War I, Sir Robert Jones developed a set of tendon transfers for radial nerve paralysis, which formed the basis for reconstructive tendon transfer surgery (...) , tenodesis, capsulodesis, and pulley release Protect the tendon transfer postoperatively, with no tension on the transfer; for example, if a tendon passes volarly, the wrist is splinted in palmar flexion The first three steps in the above list are also referred to as the three-column theory or principle for tendon transfers. Drawing out these steps in three columns facilitates the decision-making process. Previous Next: Radial Nerve Paralysis Tendon transfers for radial nerve paralysis have the best

2014 eMedicine Surgery

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