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Scaphoid Shift Test

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21. Diaphragmatic Hernias (Follow-up)

the concept of the hidden mortality of congenital diaphragmatic hernia. Image courtesy of Michael Harrison, MD. Photograph of a one-day-old infant with congenital diaphragmatic hernia. Note the scaphoid abdomen. This occurs if significant visceral herniation into the chest is present. Radiograph of an infant with congenital diaphragmatic hernia. Note shift of the mediastinum to the right, air-filled bowel in the left chest, and the position of the orogastric tube. Newborn baby with congenital (...) or skin can be safely accomplished. The use of chest tubes is controversial, as is the use of suction. The authors prefer to use a chest tube but limit suction to 5 cm H 2 O. Most authors in North America suggest avoiding the use of suction to minimize mediastinal shift. The patient with a right-side defect and an intrathoracic liver presents unique problems to the surgeon. The neonatal liver is extremely friable, and kinking of the hepatic veins and the inferior vena cava can accompany the return

2014 eMedicine Pediatrics

22. Evaluation of the Pediatric Surgical Patient (Follow-up)

of the abdomen may also be a clue to guide diagnosis. A scaphoid abdomen in a neonate or infant may suggest a diaphragmatic hernia but may be normal in a thin child. Intestinal obstruction, an abdominal mass, or ascitic fluid may cause abdominal distention. Second, listen for bowel sounds. Be patient because up to 2 minutes may pass before bowel sounds are heard. The absence of bowel sounds may suggest peritonitis. The character of the bowel sounds is also important; high-pitched sounds are consistent (...) attention must be given to modesty during the genital examination. In addition, always ensure that a staff person of the same sex as the patient is present in the room during the examination. Genital examination in boys is necessary in the evaluation of a number of conditions, including hydroceles and undescended testes. The genital examination is one of the least comfortable parts of the physical examination; boys can assume the position most comfortable for them—lying down, sitting frog-legged

2014 eMedicine Pediatrics

23. Neonatal Resuscitation (Overview)

dioxide between the mother and fetus. Second, several factors result in the lowering of maternal pH and increasing of fetal pH, which results in increased transfer of oxygen from maternal to fetal hemoglobin or red blood cells (RBCs). Maternal blood, carrying oxygen on adult hemoglobin, releases oxygen to the fetal circulation and accepts both carbon dioxide and various byproducts of metabolism from the fetal circulation. These transfers decrease maternal placental blood pH and shift the maternal (...) oxygen-dissociation curve to the right, which results in lower affinity of the hemoglobin for oxygen and the release of additional oxygen to the fetal hemoglobin. The corresponding shift in the fetal oxygen-dissociation curve to the left allows the fetal hemoglobin to bind more oxygen. Additionally, the fetal circulation contains a higher hematocrit and hemoglobin content as well as fetal hemoglobin (HgbF), which has a higher affinity for oxygen. This higher affinity for oxygen allows the fetus

2014 eMedicine Pediatrics

24. Neonatal Resuscitation (Treatment)

dioxide between the mother and fetus. Second, several factors result in the lowering of maternal pH and increasing of fetal pH, which results in increased transfer of oxygen from maternal to fetal hemoglobin or red blood cells (RBCs). Maternal blood, carrying oxygen on adult hemoglobin, releases oxygen to the fetal circulation and accepts both carbon dioxide and various byproducts of metabolism from the fetal circulation. These transfers decrease maternal placental blood pH and shift the maternal (...) oxygen-dissociation curve to the right, which results in lower affinity of the hemoglobin for oxygen and the release of additional oxygen to the fetal hemoglobin. The corresponding shift in the fetal oxygen-dissociation curve to the left allows the fetal hemoglobin to bind more oxygen. Additionally, the fetal circulation contains a higher hematocrit and hemoglobin content as well as fetal hemoglobin (HgbF), which has a higher affinity for oxygen. This higher affinity for oxygen allows the fetus

2014 eMedicine Pediatrics

25. Diaphragmatic Hernias (Treatment)

the concept of the hidden mortality of congenital diaphragmatic hernia. Image courtesy of Michael Harrison, MD. Photograph of a one-day-old infant with congenital diaphragmatic hernia. Note the scaphoid abdomen. This occurs if significant visceral herniation into the chest is present. Radiograph of an infant with congenital diaphragmatic hernia. Note shift of the mediastinum to the right, air-filled bowel in the left chest, and the position of the orogastric tube. Newborn baby with congenital (...) or skin can be safely accomplished. The use of chest tubes is controversial, as is the use of suction. The authors prefer to use a chest tube but limit suction to 5 cm H 2 O. Most authors in North America suggest avoiding the use of suction to minimize mediastinal shift. The patient with a right-side defect and an intrathoracic liver presents unique problems to the surgeon. The neonatal liver is extremely friable, and kinking of the hepatic veins and the inferior vena cava can accompany the return

2014 eMedicine Pediatrics

26. Evaluation of the Pediatric Surgical Patient (Treatment)

of the abdomen may also be a clue to guide diagnosis. A scaphoid abdomen in a neonate or infant may suggest a diaphragmatic hernia but may be normal in a thin child. Intestinal obstruction, an abdominal mass, or ascitic fluid may cause abdominal distention. Second, listen for bowel sounds. Be patient because up to 2 minutes may pass before bowel sounds are heard. The absence of bowel sounds may suggest peritonitis. The character of the bowel sounds is also important; high-pitched sounds are consistent (...) attention must be given to modesty during the genital examination. In addition, always ensure that a staff person of the same sex as the patient is present in the room during the examination. Genital examination in boys is necessary in the evaluation of a number of conditions, including hydroceles and undescended testes. The genital examination is one of the least comfortable parts of the physical examination; boys can assume the position most comfortable for them—lying down, sitting frog-legged

2014 eMedicine Pediatrics

27. Congenital Diaphragmatic Hernia (Overview)

respirations) In left-sided posterolateral hernia: Poor air entry on the left, with a shift of cardiac sounds over the right chest; in patients with severe defects, signs of pneumothorax (poor air entry, poor perfusion) may also be found Associated anomalies: Dysmorphisms such as craniofacial abnormalities, extremity abnormalities, or spinal dysraphism may suggest syndromic congenital diaphragmatic hernia Laboratory tests Laboratory studies that may be indicated in congenital diaphragmatic hernia include (...) types of congenital diaphragmatic hernia: the posterolateral Bochdalek hernia (occurring at approximately 6 weeks' gestation), the anterior Morgagni hernia, and the hiatus hernia. Radiograph of a 1-day-old infant with a moderate-sized congenital diaphragmatic hernia (CDH). Note the air- and fluid-filled bowel loops in the left chest, the moderate shift of the mediastinum into the right chest, and the position of the orogastric tube. Signs and symptoms Infants with congenital diaphragmatic hernias

2014 eMedicine Pediatrics

28. Ulnar-Sided Wrist Pain (Overview)

, followed by determination of the range of motion and palpation. Often, physicians delay palpation or movement of the wrist until the end of the examination. In that way, other disorders can be excluded systematically while the patient is still fully cooperative. Finally, special provocative tests (eg, triquetrolunate ballottement, ulnar ballottement, midcarpal shifting) can be performed to confirm the suspected pathology (see Provocative Maneuvers). Upon inspection, note any swelling, erythema (...) if the patient's pain is reproduced, suggesting triquetral chondromalacia or lunotriquetral injury. In addition, the examiner may wish to inject approximately 0.5 mL of lidocaine into the lunotriquetral joint to differentiate intra-articular from extra-articular pathology. Provocative testing for midcarpal shift To test for midcarpal instability on the right wrist, the examiner stabilizes the patient's forearm, with the left hand in a pronated position. [ ] With the patient's wrist in 15° of ulnar deviation

2014 eMedicine Surgery

29. Carpal Ligament Instability (Treatment)

. The pivot point is at the center of rotation of the capitate and lunate. This joint, without other supporting structures, is stable only in tension. It is unstable in compression, as this figure depicts, and tends to collapse. The scaphoid acts like a bridge between the proximal and distal row and protects the link from collapsing. Mayfield perilunate instability pattern. Copyright Mayo Clinic, used with permission of the Mayo Foundation. (Click Image to enlarge.) Watson scaphoid shift test. (Click (...) governing the rotational shift of the intercalated segment of the carpus. Orthop Clin North Am . 1984 Apr. 15(2):193-207. . Craigen MA, Stanley JK. Wrist kinematics. Row, column or both?. J Hand Surg Br . 1995 Apr. 20 (2):165-70. . Garcia-Elias M, Ribe M, Rodriguez J, Cots M, Casas J. Influence of joint laxity on scaphoid kinematics. J Hand Surg Br . 1995 Jun. 20 (3):379-82. . Lichtman DM, Bruckner JD, Culp RW, Alexander CE. Palmar midcarpal instability: results of surgical reconstruction. J Hand Surg

2014 eMedicine Surgery

30. Swan-Neck Deformity (Overview)

for deficient EPL function. To test for EPL tendon rupture, palpate the tendon at the wrist while the patient extends the thumb with the palm resting on a flat surface. Active testing may also reveal some weakness and pain at the site of rupture. Significant deformity or functional loss is an indication for repair by end-to-end repair, tendon graft, or to avoid flexion contraction. [ , ] Tendon transfer with the extensor indicis proprius or extensor carpi radialis longus is the preferred method (...) quinti function reduces small finger extension at the MP joint by 30-40°. Any greater loss usually indicates the extensor digiti communis tendon has also been affected. The lesion is a sign of loss of extension in the little and ring fingers due to rupture of these tendons at the distal ulnar head, which can result from caput ulna syndrome. Small finger extension can be tested by having the patient extend the small finger while the index, middle, and ring fingers are held in flexion. A small finger

2014 eMedicine Surgery

31. Neonatal Resuscitation (Diagnosis)

dioxide between the mother and fetus. Second, several factors result in the lowering of maternal pH and increasing of fetal pH, which results in increased transfer of oxygen from maternal to fetal hemoglobin or red blood cells (RBCs). Maternal blood, carrying oxygen on adult hemoglobin, releases oxygen to the fetal circulation and accepts both carbon dioxide and various byproducts of metabolism from the fetal circulation. These transfers decrease maternal placental blood pH and shift the maternal (...) oxygen-dissociation curve to the right, which results in lower affinity of the hemoglobin for oxygen and the release of additional oxygen to the fetal hemoglobin. The corresponding shift in the fetal oxygen-dissociation curve to the left allows the fetal hemoglobin to bind more oxygen. Additionally, the fetal circulation contains a higher hematocrit and hemoglobin content as well as fetal hemoglobin (HgbF), which has a higher affinity for oxygen. This higher affinity for oxygen allows the fetus

2014 eMedicine Pediatrics

32. Evaluation of the Pediatric Surgical Patient (Overview)

of the abdomen may also be a clue to guide diagnosis. A scaphoid abdomen in a neonate or infant may suggest a diaphragmatic hernia but may be normal in a thin child. Intestinal obstruction, an abdominal mass, or ascitic fluid may cause abdominal distention. Second, listen for bowel sounds. Be patient because up to 2 minutes may pass before bowel sounds are heard. The absence of bowel sounds may suggest peritonitis. The character of the bowel sounds is also important; high-pitched sounds are consistent (...) attention must be given to modesty during the genital examination. In addition, always ensure that a staff person of the same sex as the patient is present in the room during the examination. Genital examination in boys is necessary in the evaluation of a number of conditions, including hydroceles and undescended testes. The genital examination is one of the least comfortable parts of the physical examination; boys can assume the position most comfortable for them—lying down, sitting frog-legged

2014 eMedicine Pediatrics

33. Congenital Diaphragmatic Hernia (Diagnosis)

, grunting respirations) In left-sided posterolateral hernia: Poor air entry on the left, with a shift of cardiac sounds over the right chest; in patients with severe defects, signs of pneumothorax (poor air entry, poor perfusion) may also be found Associated anomalies: Dysmorphisms such as craniofacial abnormalities, extremity abnormalities, or spinal dysraphism may suggest syndromic congenital diaphragmatic hernia Laboratory tests Laboratory studies that may be indicated in congenital diaphragmatic (...) . There are 3 basic types of congenital diaphragmatic hernia: the posterolateral Bochdalek hernia (occurring at approximately 6 weeks' gestation), the anterior Morgagni hernia, and the hiatus hernia. Radiograph of a 1-day-old infant with a moderate-sized congenital diaphragmatic hernia (CDH). Note the air- and fluid-filled bowel loops in the left chest, the moderate shift of the mediastinum into the right chest, and the position of the orogastric tube. Signs and symptoms Infants with congenital

2014 eMedicine Pediatrics

34. Evaluation of the Pediatric Surgical Patient (Diagnosis)

of the abdomen may also be a clue to guide diagnosis. A scaphoid abdomen in a neonate or infant may suggest a diaphragmatic hernia but may be normal in a thin child. Intestinal obstruction, an abdominal mass, or ascitic fluid may cause abdominal distention. Second, listen for bowel sounds. Be patient because up to 2 minutes may pass before bowel sounds are heard. The absence of bowel sounds may suggest peritonitis. The character of the bowel sounds is also important; high-pitched sounds are consistent (...) attention must be given to modesty during the genital examination. In addition, always ensure that a staff person of the same sex as the patient is present in the room during the examination. Genital examination in boys is necessary in the evaluation of a number of conditions, including hydroceles and undescended testes. The genital examination is one of the least comfortable parts of the physical examination; boys can assume the position most comfortable for them—lying down, sitting frog-legged

2014 eMedicine Pediatrics

35. Swan-Neck Deformity (Treatment)

for deficient EPL function. To test for EPL tendon rupture, palpate the tendon at the wrist while the patient extends the thumb with the palm resting on a flat surface. Active testing may also reveal some weakness and pain at the site of rupture. Significant deformity or functional loss is an indication for repair by end-to-end repair, tendon graft, or to avoid flexion contraction. [ , ] Tendon transfer with the extensor indicis proprius or extensor carpi radialis longus is the preferred method (...) quinti function reduces small finger extension at the MP joint by 30-40°. Any greater loss usually indicates the extensor digiti communis tendon has also been affected. The lesion is a sign of loss of extension in the little and ring fingers due to rupture of these tendons at the distal ulnar head, which can result from caput ulna syndrome. Small finger extension can be tested by having the patient extend the small finger while the index, middle, and ring fingers are held in flexion. A small finger

2014 eMedicine Surgery

36. Ulnar-Sided Wrist Pain (Treatment)

, followed by determination of the range of motion and palpation. Often, physicians delay palpation or movement of the wrist until the end of the examination. In that way, other disorders can be excluded systematically while the patient is still fully cooperative. Finally, special provocative tests (eg, triquetrolunate ballottement, ulnar ballottement, midcarpal shifting) can be performed to confirm the suspected pathology (see Provocative Maneuvers). Upon inspection, note any swelling, erythema (...) if the patient's pain is reproduced, suggesting triquetral chondromalacia or lunotriquetral injury. In addition, the examiner may wish to inject approximately 0.5 mL of lidocaine into the lunotriquetral joint to differentiate intra-articular from extra-articular pathology. Provocative testing for midcarpal shift To test for midcarpal instability on the right wrist, the examiner stabilizes the patient's forearm, with the left hand in a pronated position. [ ] With the patient's wrist in 15° of ulnar deviation

2014 eMedicine Surgery

37. Carpal Ligament Instability (Follow-up)

. The pivot point is at the center of rotation of the capitate and lunate. This joint, without other supporting structures, is stable only in tension. It is unstable in compression, as this figure depicts, and tends to collapse. The scaphoid acts like a bridge between the proximal and distal row and protects the link from collapsing. Mayfield perilunate instability pattern. Copyright Mayo Clinic, used with permission of the Mayo Foundation. (Click Image to enlarge.) Watson scaphoid shift test. (Click (...) governing the rotational shift of the intercalated segment of the carpus. Orthop Clin North Am . 1984 Apr. 15(2):193-207. . Craigen MA, Stanley JK. Wrist kinematics. Row, column or both?. J Hand Surg Br . 1995 Apr. 20 (2):165-70. . Garcia-Elias M, Ribe M, Rodriguez J, Cots M, Casas J. Influence of joint laxity on scaphoid kinematics. J Hand Surg Br . 1995 Jun. 20 (3):379-82. . Lichtman DM, Bruckner JD, Culp RW, Alexander CE. Palmar midcarpal instability: results of surgical reconstruction. J Hand Surg

2014 eMedicine Surgery

38. Ulnar-Sided Wrist Pain (Diagnosis)

, followed by determination of the range of motion and palpation. Often, physicians delay palpation or movement of the wrist until the end of the examination. In that way, other disorders can be excluded systematically while the patient is still fully cooperative. Finally, special provocative tests (eg, triquetrolunate ballottement, ulnar ballottement, midcarpal shifting) can be performed to confirm the suspected pathology (see Provocative Maneuvers). Upon inspection, note any swelling, erythema (...) if the patient's pain is reproduced, suggesting triquetral chondromalacia or lunotriquetral injury. In addition, the examiner may wish to inject approximately 0.5 mL of lidocaine into the lunotriquetral joint to differentiate intra-articular from extra-articular pathology. Provocative testing for midcarpal shift To test for midcarpal instability on the right wrist, the examiner stabilizes the patient's forearm, with the left hand in a pronated position. [ ] With the patient's wrist in 15° of ulnar deviation

2014 eMedicine Surgery

39. Swan-Neck Deformity (Follow-up)

for deficient EPL function. To test for EPL tendon rupture, palpate the tendon at the wrist while the patient extends the thumb with the palm resting on a flat surface. Active testing may also reveal some weakness and pain at the site of rupture. Significant deformity or functional loss is an indication for repair by end-to-end repair, tendon graft, or to avoid flexion contraction. [ , ] Tendon transfer with the extensor indicis proprius or extensor carpi radialis longus is the preferred method (...) quinti function reduces small finger extension at the MP joint by 30-40°. Any greater loss usually indicates the extensor digiti communis tendon has also been affected. The lesion is a sign of loss of extension in the little and ring fingers due to rupture of these tendons at the distal ulnar head, which can result from caput ulna syndrome. Small finger extension can be tested by having the patient extend the small finger while the index, middle, and ring fingers are held in flexion. A small finger

2014 eMedicine Surgery

40. Ulnar-Sided Wrist Pain (Follow-up)

, followed by determination of the range of motion and palpation. Often, physicians delay palpation or movement of the wrist until the end of the examination. In that way, other disorders can be excluded systematically while the patient is still fully cooperative. Finally, special provocative tests (eg, triquetrolunate ballottement, ulnar ballottement, midcarpal shifting) can be performed to confirm the suspected pathology (see Provocative Maneuvers). Upon inspection, note any swelling, erythema (...) if the patient's pain is reproduced, suggesting triquetral chondromalacia or lunotriquetral injury. In addition, the examiner may wish to inject approximately 0.5 mL of lidocaine into the lunotriquetral joint to differentiate intra-articular from extra-articular pathology. Provocative testing for midcarpal shift To test for midcarpal instability on the right wrist, the examiner stabilizes the patient's forearm, with the left hand in a pronated position. [ ] With the patient's wrist in 15° of ulnar deviation

2014 eMedicine Surgery

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