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The patient’s pancreas will produce less in- calcium absorption generic motilium 10 mg line, increasing urinary calcium loss order 10 mg motilium free shipping, inhibit- sulin motilium 10mg amex, and thus buy 10 mg motilium free shipping, more exogenous insulin will need to be pro- ing secretion of sex hormones, and other effects. If the patient were to regain weight, he would most likely hol intake, and being female. He does appear, however, to have to go back to taking insulin injections. PART X Reproductive Physiology CHAPTER The Male Reproductive System Paul F. LH and FSH secretion by the anterior pituitary are con- sis of testosterone by Leydig cells, and follicle-stimulating trolled by gonadotropin-releasing hormone (GnRH). Androgens have several target organs and have roles in through a series of developmental stages that include regulating the development of secondary sex characteris- spermatocytes and spermatids. The most potent natural androgen is dihydrotestosterone, time of ejaculation, sperm are moved by muscular contrac- which is produced from the precursor, testosterone, by the tions of the epididymis and vas deferens through the ejacu- action of the enzyme 5 -reductase. Male reproductive dysfunction is often due to a lack of LH moved out of the body through the urethra in the penis. Testosterone is the primary sex hormone in AN OVERVIEW OF THE MALE the male and is responsible for primary and secondary sex REPRODUCTIVE SYSTEM characteristics. The primary sex characteristics include those structures responsible for promoting the develop- A diagram of reproduction regulation in the male is pre- ment, preservation, and delivery of sperm. The system is divided into factors af- ary sex characteristics are those structures and behavioral fecting male function: brain centers, which control pitu- features that make men externally different from women itary release of hormones and sexual behavior; gonadal 649 650 PART X REPRODUCTIVE PHYSIOLOGY Environment ported via the urethra through the penis and are ultimately Age Drugs expelled by ejaculation. The accessory structures of the male reproductive tract include the prostate gland, seminal vesicles, and bulbourethral glands. These glands contribute Brain several constituents to the seminal fluid that are necessary centers for maintaining functional sperm. Hypothalamus REGULATION OF TESTICULAR FUNCTION GnRH Testicular function is regulated by LH and FSH. LH regu- lates the secretion of testosterone by the Leydig cells and Anterior pituitary FSH, in synergy with testosterone, regulates the produc- tion of spermatozoa. FSH LH Inhibin Follistatin Hypothalamic Neurons Produce Testes Gonadotropin-Releasing Hormone Activin Hypothalamic neurons produce gonadotropin-releasing Testosterone hormone (GnRH), a decapeptide, which regulates the se- cretion of luteinizing hormone (LH) and follicle-stimulat- Accessory ing hormone (FSH). Although neurons that produce Behavior Secondary sex GnRH can be located in various areas of the brain, their reproductive characteristics tissues highest concentration is in the medial basal hypothalamus, in the region of the infundibulum and arcuate nucleus. GnRH enters the hypothalamic-pituitary portal system and The main reproductive hormones are shown in binds to receptors on the plasma membranes of pituitary boxes. Positive and negative regulations are depicted by plus and minus signs, respectively. A variety of external cues and internal signals influence the secretion of GnRH, LH, and FSH. For example, the structures, which produce sperm and hormones; a ductal amount of GnRH, FSH, and LH secreted changes with age, system, which stores and transports sperm; and accessory stress levels, and hormonal state. Little, if any, The endocrine glands of the male reproductive system secretion of hypothalamic GnRH occurs in patients with include the hypothalamus, anterior pituitary, and testes. GnRH moves down the hypothalamic- nadal from a deficiency in LH and FSH secretion because pituitary portal system and stimulates the secretion of LH of a failure of GnRH neurons to migrate from the olfactory and FSH by the gonadotrophs of the anterior pituitary. These patients do binds to receptors on the Leydig cells and FSH binds to re- not have a sufficient hypothalamic source of GnRH to ceptors on the Sertoli cells. Leydig cells reside in the inter- maintain secretion of LH and FSH, and the testes fail to un- stitium of the testes, between seminiferous tubules, and dergo significant development. Sertoli cells are located within the GnRH originates from a large precursor molecule called seminiferous tubules, support spermatogenesis, contain preproGnRH (Fig. PreproGnRH consists of a signal FSH and testosterone receptors, and produce estradiol, al- peptide, native GnRH, and a GnRH-associated peptide beit at low levels. The signal peptide (or leader sequence) allows the Testosterone belongs to a class of steroid hormones, the protein to cross the membrane of the rough ER. Sertoli cells also produce glycoprotein hormones— nhibin, activin, and Three distinct pituitary LH- and FSH-secreting cells have follistatin—that regulate the secretion of FSH. Gonadotrophs contain either LH or FSH, The duct system that transports sperm from the testis to and some cells contain both LH and FSH.
Articular facets on the articular surface of the patella ar- The foot contains 26 bones purchase motilium 10 mg without prescription, grouped into the tarsus purchase motilium 10 mg overnight delivery, metatarsus 10mg motilium fast delivery, ticulate with the medial and lateral condyles of the femur buy discount motilium 10 mg online. Although similar to the bones of the The functions of the patella are to protect the knee joint hand, the bones of the foot have distinct structural differences in and to strengthen the patellar tendon. It also increases the lever- order to support the weight of the body and provide leverage and age of the quadriceps femoris muscle as it extends (straightens) mobility during walking. It usually does Tarsus not fragment, however, because it is confined within the patel- lar tendon. Dislocations of the patella may result from injury or from There are seven tarsal bones. The most superior in position is the underdevelopment of the lateral condyle of the femur. Leg It has a large posterior extension, called the tuberosity of the Technically speaking, leg refers only to that portion of the lower limb between the knee and foot. Skeletal System: The © The McGraw−Hill Anatomy, Sixth Edition Appendicular Skeleton Companies, 2001 186 Unit 4 Support and Movement Base of patella Articular surface Anterior surface Medial Apex of patella condyle Intercondylar eminence Intercondylar eminence Lateral condyle Articular surface of fibular head Head of fibula Tibial tuberosity Fibular articular Neck of fibula surface Anterior border Body of Body of tibia fibula Patella Tibia Fibula Medial malleolus Lateral malleolus Lateral malleolus (a) (b) FIGURE 7. Anterior to differ in shape, however, because of their load-bearing role. The remaining four The metatarsal bones are numbered I to V, starting with the tarsal bones form a distal series that articulate with the medial (great toe) side of the foot. The proximal bases of the first, second, and third metatarsals ar- Metatarsus ticulate proximally with the cuneiform bones. The heads of the metatarsals articulate distally with the proximal phalanges. The The metatarsal bones and phalanges are similar in name and proximal joints are called tarsometatarsal joints, and the distal number to the metacarpals and phalanges of the hand. The ball of the foot is formed by the heads of the first two calcaneus: L. Skeletal System: The © The McGraw−Hill Anatomy, Sixth Edition Appendicular Skeleton Companies, 2001 Chapter 7 Skeletal System: The Appendicular Skeleton 187 Sesamoid bone Distal Metatarsal Talus phalanx bones Distal phalanx Cuneiform Tibia Phalanges Proximal bone Middle phalanx Fibula phalanx Navicular Proximal phalanx bone Calcaneus Metatarsal Medial I II cuneiform bone bones III IV V Intermediate cuneiform bone Lateral cuneiform bone Tarsal Navicular bone bones Cuboid bone Talus Calcaneus (a) (b) I II III Distal phalanx IV Phalanges Proximal phalanx V Distal phalanx Middle phalanx Head Proximal phalanx First metatarsal bone Body Metatarsal bones Medial cuneiform Fifth metatarsal bone bone Base Intermediate cuneiform bone Lateral cuneiform bone Navicular bone Cuboid bone Talus Calcaneus Tarsal bones Tuberosity of calcaneus (c) (d) FIGURE 7. Each digit (toe) is indicated by a Roman numeral, the first digit, or great toe, being Roman numeral I. Skeletal System: The © The McGraw−Hill Anatomy, Sixth Edition Appendicular Skeleton Companies, 2001 188 Unit 4 Support and Movement Phalanges The 14 phalanges are the skeletal elements of the toes. As with the fingers of the hand, the phalanges of the toes are arranged in a proximal row, a middle row, and a distal row. The great toe, or hal- Cuneiform lux (adjective, hallucis) has only a proximal and a distal phalanx. They are formed by the structure and Talus arrangement of the bones and maintained by ligaments and ten- Calcaneus dons (fig. The arches are not rigid; they “give” when Navicular bone weight is placed on the foot, and they spring back as the weight Transverse arch is lifted. Longitudinal arch The longitudinal arch is divided into medial and lateral parts. The talus First metatarsal bone is keystone of the medial part, which originates at the calcaneus, rises at the talus, and descends to the first three metatarsal bones. Phalanges of big toe The shallower lateral part consists of the calcaneus, cuboid, and (a) fourth and fifth metatarsal bones. The transverse arch extends across the width of the foot Bases of and is formed by the calcaneus, navicular, and cuboid bones pos- metatarsal bones teriorly and the bases of all five metatarsal bones anteriorly. A weakening of the ligaments and tendons of the foot may cause the arches to “fall”—a condition known as pes planus, or, Transverse arch more commonly, “flatfoot. Skeletal System: The © The McGraw−Hill Anatomy, Sixth Edition Appendicular Skeleton Companies, 2001 Chapter 7 Skeletal System: The Appendicular Skeleton 189 FIGURE 7.
Vaccaro AR discount motilium 10 mg online, Kim DH proven 10mg motilium, Brodke DS et al (2003) Diagnosis and management of thoracolumbar spine fractures proven motilium 10 mg. J Bone Joint Surg Am 85:2456-2470 IDKD 2005 Trauma of the Appendicular Skeleton J motilium 10 mg free shipping. Dalinka2 1 Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA 2 Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA Introduction prompt a search for a fracture of the other paired bone or for a dislocation of the proximal or distal joint. In the Trauma to the appendicular skeleton is exceedingly com- case of examination of joints and in the hands and feet, mon. An understanding of normal radiographic anatomy three views are traditionally obtained, although the use of is therefore essential in interpreting images of the appen- the opposite oblique has been suggested in the hand. Certain anatomic sites are associated The exception to this may be in the hip, shoulder, or the with particular injuries, and knowledge of the injuries knee, where two views are commonly sufficient. Nonetheless, whenever doubt occurs, supplemental views Problems in the diagnosis of trauma of the appendicu- are often helpful. In multitrauma patients, shortcuts are often tak- particularly in areas of complex anatomy (e. CT are frequently incomplete and the images obtained may with reformatted images is often used in treatment plan- be marginal or subopitimal. Consequently, attempts to in- ning in patients with fractures at the ends of long bones, terpret such images may lead to diagnostic errors. In addition, many errors are sec- demonstrating occult fractures (those fractures not visu- ondary to an inadequate or incomplete history; it has alized with conventional imaging techniques), in detect- been shown that, when the history is specific, the miss ing incomplete fractures (particularly in the femoral neck rate in cases of subtle injury can be reduced by approxi- and about the hip), and in establishing a diagnosis of fa- mately 50%. In addition to detecting acute injuries, in many cases radiologists are called upon to do follow-up imaging in patients with persistent pain following trauma. In these Specific Sites – Upper Extremity cases, the fracture may have been initially occult, or sub- tle findings may have been overlooked. Chronic repeti- Shoulder tive trauma is another cause of skeletal injury in which radiographic abnormalities may not be detectable on the As noted above, two views of the shoulder are often ob- initial images and for which follow-up studies are fre- tained in order to evaluate for traumatic abnormalities. The ACR has developed appropriate- the past, these were typically AP views in both internal ness criteria to help address this issue. Currently, many centers also use a direct AP view or a Grashey view (which is a 45° oblique view of the glenohumeral joint), some combination of a Techniques scapular “Y” projection (60° anterior oblique of scapula), or an axillary or apical oblique (Garth) view (45° poste- In the long bones of the extremities, two views are gen- rior oblique with 45° of caudal angulation) [4, 5]. It is important that the examinations in- views are particularly helpful in evaluating posterior dis- clude the proximal and distal joints, which sometimes re- locations of the shoulder. These views require moving the quire additional images particularly in large patients. In injured shoulder rather than the patient, and are some- the case of paired long bones (the leg or forearm), the de- times difficult to obtain. They are more readily obtained tection of the fracture of a single bone should always by technologists than scapular-Y views. Dalinka is helpful in evaluating the glenoid process of the scapu- seen on CT examinations. Sternoclavicular dislocations la as well as the precise location of the humeral head with may be anterior or posterior; of these, posterior disloca- respect to the glenoid. CT allows evalu- ulation is fracture of the surgical neck of the humerus. It is important to mention displacement of fragments, as this affects management. Fractures of the scapula, which Elbow may extend to the glenoid process and become intra-ar- ticular, are commonly seen in younger patients who have Conventional radiographic imaging of the elbow should sustained severe trauma. Displacement and elevation of these fat pads is a reliable Dislocations occurring commonly at the shoulder in- sign of intra-articular fluid. In the setting of trauma, the clude acromioclavicular joint separations; these may re- presence of displaced anterior and posterior fat pads at quire stress radiographs when initial images show no sep- the elbow should be considered presumptive evidence of aration at the acromioclavicular joint. The cortical sur- these structures may sometimes lead to surgical therapy.
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