By V. Yussuf. College of William and Mary. 2018.
Intra-articular injec- Knee Pain 107 tions of corticosteroid and anesthetic may also be helpful buy 40mg inderal free shipping. Surgical options are reserved for persistent or severe symptoms and include arthroscopy buy inderal 40 mg lowest price, osteotomy order 80 mg inderal free shipping, and total knee replacement buy inderal 80 mg lowest price. Treatment: NSAIDs, activity modification, knee pads, and a corti- costeroid and anesthetic injection may be helpful. Treatment: NSAIDs, rest, activity modification, physical therapy emphasizing stretching and strengthening of the hamstrings and quadri- ceps and a corticosteroid and anesthetic injection may be helpful. Depending on the age of the patient and extent of injury, surgery may be necessary. Adults generally require surgery, whereas children and ado- lescents with skeletally immature bones may be treated conservatively. Treatment: Activity restriction and/or modification, an infrapatellar strap, and physical therapy emphasizing stretching and strengthening of the quadriceps and hamstrings, are generally sufficient for treatment. Less common problems that you must still consider include capsu- lar injury, posterior tibial tendonitis, tarsal tunnel syndrome, osteo- chondritis dissecans (OCD), and anterior impingement syndrome. The history and physical examination will help you narrow your differen- tial diagnosis. Medial pain suggests a ligament injury (rare on the medial side), possible fracture, or posterior tibial ten- donitis. Anterior pain suggests anterior capsule injury or anterior bony impingement. OCD may occur on the lateral or medial aspect of the ankle, but it is a relatively uncommon disorder. In fact, between knowing the location of the patient’s pain and how the pain started, you may be From: Pocket Guide to Musculoskeletal Diagnosis By: G. Almost all ankle sprains are lateral sprains and occur after an inver- sion injury. The typical history a patient will give is falling over a turned-in (inverted) ankle while playing a sport or walking in the street. However, if the patient suffered an ankle fracture, he or she will give a history of a more significant trauma, such as participation in a sporting event in which another player fell on the ankle. If the patient has an anterior capsular strain, the patient may be a softball or baseball player who was injured during a hook-slide into a base. If the patient has Achilles tendonitis, he or she may be a runner, dancer, or other athlete who complains of gradually increasing pain in the Achilles tendon that is made worse with activity. If the patient has posterior tibial tendonitis, the patient is probably a young runner who presents with a complaint of pain at the medial aspect of the ankle with weight-bearing. The patient will report that the pain is worse in the morning and also increases with activity. If the patient has anterior bony impingement syndrome, the patient may be a dancer or basketball player who recalls a history of trauma leading to acute pain followed by chronic, vague pain that is made worse on landing from jumps. OCD is a condition in which a fragment of cartilage and subchondral bone separates from an intact articular surface. In contrast to OCD in other parts of the body, ankle OCD is more typically precipitated by a traumatic insult. This question is important for many reasons including that patients with a history of ankle surgery are predisposed to premature osteoarthritis in the ankle. What is the quality of your ankle pain (sharp, shooting, dull, aching, burning)? Patients with tarsal tunnel syndrome may have shooting pains, tin- gling, and burning radiating from the tarsal tunnel (posterior to the medial malleolus) to the sole of the foot. The answer to this ques- tion is also useful for obtaining a gestalt of the patient’s pain.
Since patients with or without an epicondylar with internal rotation should be recorded if the findings pseudarthrosis are usually symptom-free buy 80 mg inderal amex, the pri- are unclear purchase 80 mg inderal overnight delivery. Fracture types Cases of symptomatic pseudarthrosis can be managed The radial condyle is by far the most commonly affected inderal 80mg low cost. Completely intra-articular fractures ▬ Medial instability with pseudarthrotic healing is rare with rupture of the epiphyseal cartilage are unstable and and often leads to symptoms at a late stage discount 80 mg inderal with mastercard. Incomplete articular fracture of the radial condyle of the complete articular fracture can even be displaced secondarily during humerus ( a): This so-called »hanging« fracture can be treated conserva- cast immobilization and lead to pseudarthroses. Complete articular placement – as a sign of a complete articular fracture – must be identi- fracture of the radial condyle of the humerus (b): The non-displaced, fied as such and the fracture can then be managed surgically! The poste- cartilage-bone junction is less than 2 mm, it may be rior soft tissues over the condyle must be preserved so assumed that the cartilage is also intact. Exposure of the posterior, metaphyseal fracture sections is essential Employing this simple, radiological criterion, we have not for both the reduction and accurate implant place- missed any cases of primary or secondary displacement ment. The diagnosis based on the trauma x-ray screw produces secure fixation, consolidation within 4 is clear only if the fracture is completely displaced. If it weeks and thus the prevention of partially stimulatory initially appears non-displaced or minimally displaced, growth disturbances. A cast-free check x-ray after 5–7 days is essential in order to check for secondary dislocation. Follow-up controls Ulnar condylar fractures and Y- or T fractures are much Consolidation x-ray after 4–5 weeks. The diagnostic considerations for radial condylar removal after 3–4 months. Full elbow mobility is usu- Treatment ally restored only after several months. Physiotherapy is Conservative indicated only if movement restrictions persist for several Non-displaced fractures undergo bone healing in a months. Fishtail deformity: After the distal epiphysis has ossi- fied, one occasionally sees a central bony retraction Surgical in otherwise normal, but now more prominent, con- ▬ Radial condyle: Primarily or secondarily displaced dyles. On the AP x-ray the distal humerus resembles fractures are anatomically reduced in an open proce- a fishtail. Conservative treatment of a fracture of the radial condyle treated conservatively. We have never observed this change in and a radial condyle that has consolidated too proximally, shape in fractures that are stably fixed with compres- or even migrated proximally after pseudarthrosis, pro- sion screws [30, 31]. It is probably a radiological phe- duce opposite effects on the elbow axis. Considerable dispute exists as to the indication, and par- The excessively large radial condyle often exagger- ticularly the appropriate age, for a revision of the pseud- ates the axial deformity. Spontaneous correction cannot be ex- ture management, lateral approaches with extensive pos- pected. The indication for a corrective osteotomy is terior soft tissue removal from the radial condyle, inade- based on the patient’s symptoms. Although the proximal radial epiphyseal plate only After supracondylar and condylar fractures, those of the accounts for 20% of the growth in length, it pos- radial head are the third commonest elbow fractures dur- sesses an impressive potential for spontaneous cor- ing growth. Mechanical factors may play a and primarily affect the age group between 4 and 14 years crucial role in this remodeling process, for example it. They are the result of an excessive valgus stress in can be activated by early independent mobilization. The primary determining prognostic factor is the Conservative treatment impairment of the blood supply via the periosteal Simple immobilization in a long-arm cast is appropriate radial neck vessels caused by the initial trauma or in the following cases: even iatrogenically through an invasive therapeutic ▬ before the age of 10 with angulations of less than procedure. Otherwise, possible compli- cations include avascular necroses, loss of the radial head Surgical treatment shape and serious functional restrictions, particularly in A closed reduction with subsequent Prévot nail fixation respect of movements with forearm rotation. In this pro- cedure, the fragment is reduced as far as possible by the Diagnosis application of external finger pressure and a concurrent Clinical features pronation/supination movement. Any residual deformity Local swelling, tenderness, painful restriction of a fore- is corrected via an elastic medullary nail advanced into arm turnover movement. The implant is advanced as far as the epiphysis, which is then reduced by rotating the Imaging investigations angled nail end (⊡ Fig.
Gastroenterologists must finish three years of training in internal medicine and complete another two years in gastroenterology inderal 40 mg sale. Hematology Hematology is the subspecialty that deals with blood order 40mg inderal with amex, blood dis- eases inderal 40mg free shipping, and the spleen and lymph glands discount 80 mg inderal visa. Many hematology training programs are connected to medical oncology programs, which treat cancer. Hematologists treat all organ systems, but always related to the blood in those systems. This is a rapidly advancing field, and diagnosis and treatment often involve the use of high-tech equipment. Hematologists must contend with the ongoing strain of death, even in the young, but not lose their compassion in the process. The rewarding aspect of this specialty comes with improving patients’ lives. Hematologists treat leukemia, other can- cers of the blood, lymphoma, sickle-cell disease, hemophilia, seri- ous anemia, and secondary problems that arise when a patient has another type of cancer. Like many other subspecialties of internal medicine, hematol- ogy is analytical and highly intellectual. Because of the research and writing involved in hematology, it is a valuable asset if the per- son choosing this field is a good writer. There were 74 residents working in 20 accredited training programs in hematology in 2002. Hematologists must finish three years of training in general internal medicine and complete another two years in a hematology training program. Infectious Disease Subspecialists in infectious disease diagnose and treat communica- ble disease. Traditionally, most infectious disease subspecialists worked in hospitals or medical centers, where difficult cases are referred. Today, however, there are more opportunities for private practice in this field. Infectious disease specialists are usually found in urban areas, where they can receive referrals from a large num- ber of other physicians. Internal Medicine Subspecialties 47 This is an intellectually challenging field that requires detective work. People are usually referred to these specialists when other physicians can’t determine the cause of the problem. For instance, when a person has a fever that cannot be explained, the patient is often referred to an infectious disease specialist. The field of infec- tious disease is very diverse, requiring the practitioner to have a wide range of clinical expertise. This specialty has changed dramatically in recent years with the advent of AIDS. For that reason, infectious disease specialists are not as well- paid as some of the more procedures-oriented specialists. As infectious diseases are transmitted from person to person, usually through some form of contact, there is also a public health aspect to this subspecialty when outbreaks occur and affect whole popu- lations of people. Most infectious disease specialists do not form long-lasting relationships with patients, with the notable exception of the case of AIDS, whereby the infectious disease specialist some- times becomes the primary care physician. There were 625 residents in training at 139 accredited training programs in infectious disease in 2002, 43 percent of whom were women. Three years of internal medicine residency are mandatory, followed by at least two years of subspecialty training in infectious diseases. Medical Oncology Medical oncology deals with tumors and cancers, which can occur in all organ systems. It is a multidisciplinary field because the medical oncolo- gist treats all or any systems, and oncologists often consult with 48 Opportunities in Physician Careers specialists in those systems. Oncology is a rapidly expanding and ever-changing discipline, and research opportunities in oncology are plentiful.
Next cheap inderal 40mg without prescription, palpate along the biceps tendon as it runs in the bicipital groove (tenderness over a tendon may reflect tendonitis) 80mg inderal. To find the bicipital groove inderal 80mg, palpate lateral to the coracoid process onto the lesser tuberosity of the humerus cheap inderal 80 mg with mastercard. Have the patient slowly internally rotate the arm and you will feel your finger come out of the groove as the groove rotates. This is a common site of inflammation and impingement of the supraspinatus tendon. Assess the patient’s range of motion by having the patient reach behind and across the back with one hand and touch the lower opposite scapula (Photo 1). Internal rotation and adduction may also be tested by having the patient reach across the chest and touch the opposite shoulder (Photo 2). Next, have the patient reach behind the neck and touch the opposite scapula (Photo 3). This is the Apley Scratch test, and it is used to assess for external rotation and abduction. This maneuver stresses the AC joint and is used to assess for AC joint injury or arthritis. Test for shoulder flexion by having the patient flex the arm against resistance. This tests the anterior portion of the deltoid, which is innervated by the axillary nerve (C5), and the coracobrachialis (C5). Test the patient’s extension by having the patient extend the upper arm against resistance. This tests the latissimus dorsi, which is inner- vated by the thoracodorsal nerve (C6–C8); the teres major, which is innervated by the lower subscapular nerve (C5–C6); and the posterior portion of the patient’s deltoid, which is innervated by the axillary nerve (C5–C6). Test the patient’s abduction by having the patient abduct the arm against resistance (Photo 5). This tests the middle portion of the deltoid, which is innervated by the axillary nerve (C5–C6); and the supraspina- tus, which is innervated by the suprascapular nerve (C5–C6). Therefore, it is important to test abduction by resisting the movement throughout its range of motion (or at least to 90°). Test the patient’s adduction by having the patient adduct the upper arm against resistance (Photo 6). This tests the patient’s pectoralis major, which is innervated by the medial and lateral anterior thoracic nerves (C5–T1); the latissimus dorsi, which is innervated by the thoracodorsal 24 Musculoskeletal Diagnosis Photo 6. Test the patient’s external rotation by having the patient externally rotate the arm against resistance (Photo 7). This tests the infraspinatus muscle, which is innervated by the suprascapular nerve (C5–C6); and the teres minor, which is innervated by the axillary nerve (C5). Test the patient’s internal rotation by having the patient internally rotate against resistance (Photo 8). This tests the patient’s subscapularis muscle, which is innervated by the upper and lower subscapular nerves (C5–C6); the pectoralis major muscle, which is innervated by the medial and lateral anterior thoracic nerves (C5–T1); the latissimus dorsi, which is innervated by the thoracodorsal nerve (C6–C8); and the teres major, which is innervated by the lower subscapular nerve (C5–C6). Test the patient’s scapular elevation by having the patient shrug his or her shoulders against resistance (Photo 9). This tests the patient’s trapezius—which is innervated by the spinal accessory nerve (cranial nerve XI)—and the levator scapulae—which is innervated by branches of the dorsal scapular nerve (C5). It is possible, although not routinely done, to test the patient’s scapular retraction by having the patient stand “at attention” by throw- ing the shoulders back against the examiner’s resistance. The examiner should provide resistance in this instance by trying to bend the patient’s shoulders forward. This tests the patient’s rhomboid major and minor muscles, both of which are innervated by the dorsal scapu- lar nerve (C5). Test for scapular protraction by having the patient push with two hands against a wall (Photo 10). This tests the patient’s serratus ante- rior muscle, which is innervated by the long thoracic nerve (C5–C7). If the serratus anterior muscle is weak, medial scapular winging will be 26 Musculoskeletal Diagnosis Photo 9. If the trapezius is weak, there may be lateral scapular winging evident.